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DENTAL   SURGERY. 


DENTAL  SURGERY 


FOE 


PRACTITIONERS  AND  STUDENTS 


BY 

ASHLEY  W.  BAKKETT,  M.B.(Lond.),M.K.C.S.,  L.D.S. 

DENTAL  SUEGEON  TO  THE  LONDON  HOSPITAL. 


PHILADELPHIA 

PEESLEY  BLAKISTON,   SON  AND  CO. 

1012  WALNUT  STREET 
1885 


PBEFACE. 


Having  stated  as  concisely  as  possible  the  substance  of  what 
for  several  years  I  have  been  teaching  to  students  of  medi- 
cine in  the  Dental  Department  of  the  London  Hospital,  I 
venture  to  hope  that  this  small  book  may  prove  useful 
to  the  busy  medical  practitioner,  too  much  occupied  to 
study  larger  and  more  exhaustive  works  on  Dental 
Surgery. 

To  such  matters  as  the  filling  of  teeth  with  gold,  the 
pivoting  of  mineral  crowns,  and  to  others  which  fall  only 
within  the  scope  of  the  specialist,  reference  is  intentionally 
omitted.  My  aim  throughout  has  been  to  give  upon 
dental  matters  as  much  practical  information,  and  no 
more,  as  may  suffice  the  student  of  medicine  in  the  after 
work  of  his  profession. 


VI  PREFACE. 

To  the  practice  and  teaching  of  my  uncle,  H.  J.  Barrett, 
I  am  mostly  indebted  for  what  may  be  found  to  possess 
value  in  these  pages;  and  to  my  brother,  S.  E.  Barrett,  my 
thanks  are  due  for  his  assistance  in  revising  the  proof 
sheets.  For  the  illustrations  of  Dental  Forceps,  I  am 
obliged  to  the  courtesy  of  Messrs.  Ash  and  Co. 


A.  W.  BAREETT. 


42  Finsbuky  Squake, 

London,  E.C. 


TABLE  OF  CONTENTS. 


CHAPTER   I. 

The  First  Dentition. 

PAGE 

Eruption  of  Temporary  Teeth.  Lancing  the  Gums.  Ab- 
sorption of  Temporary  Fangs.  When  to  Extract  Tem- 
porary Teeth  for  relief  of  Irregularity.  Undesirability 
of  Extracting  Temporary  Teeth.  Ulceration  through 
the  Gums  of  Temporary  Fangs       .....       1 

CHAPTER   II. 

The  Second  Dentition. 

Order  of  Eruption  of  Permanent  Teeth.  Eruption  of  Wis- 
dom Teeth.  Diagrams  of  Teeth  at  Three  Periods  of 
Childhood.  How  to  distinguish  between  Temporary 
and  Permanent  Teeth    .......       6 


CHAPTER   III. 

Abnormalities  in  Development  of  Permanent  Teeth. 

Retarded  Eruption.  Supernumerary  Teeth.  Abortive  Teeth. 
Dilacerated  and  Geminated  Teeth.  Honey-combed 
and  Syphilitic  Teeth 10 


Vlll  TABLE    OF    CONTENTS. 

CHAPTER    IV. 
Irregularity  in  the  Positions  of  the  Permanent  Teeth. 

PAGE 

Cause  of  Irregularity  among  Teeth  of  the  Present  Time. 
Treatment  of  Irregularity  by  Extraction  and  the  Regu- 
lating Plate.  Symmetrical  Extraction.  Six  Common 
Forms  of  Irregularity: — 1.  Underhung  Incisors;  2. 
Rotated  Incisors;  3.  Projecting  and  Diverging  In- 
cisors ;  4.  Projecting  Canines  ;  5.  The  V-shaped  Dental 
Arch;  6.  Irregular  Articulation  of  Upper  with  Lower 
Teeth.     The  Excavator  and  the  Mouth  Mirror       .         .     14 


CHAPTER   V. 

Dental  Caries. 

Tendency  of  Teeth  to  become  rudimentary.  Local  and 
General  Causes  of  Decay.  Two  Varieties  of  Caries. 
Liability  of  Various  Teeth  to  Decay.  General  Direc- 
tions as  to  Treatment  of  Caries.  Symptoms  and  Treat- 
ment of  Caries  in  its  First  Stage.  Caries  in  its  Second 
Stage,  with  Antiseptic  Treatment  of  the  Pulp  Cavity, 
and  Symptoms  and  Treatment  of  Periodontitis  and 
Alveolar  Abscess.  Caries  in  its  Third  Stage,  with 
Contraction  of  Temporo- Maxillary  Articulation  and  Fis- 
tulous opening  through  Cheek 27 


TABLE    OF    CONTENTS.  IX 

CHAPTER   VI. 

Toothache. 

PAGE 

Odontalgia.      Periodontitis.      Gas  Pressure  on    the   Nerve. 
Neuralgia      .        .  ' 

CHAPTER  VII. 

Mechanical  Injuries  to  the  Teeth. 

Wearing  down  of  the  Teeth  from  Friction  of  Mastication. 
Hunter's  Denuding  Process.  Fracture  and  Dislocation 
of  a  Tooth  from  Violence       .         .         •         •         •         •     54 

CHAPTER  VIII. 

Extraction  of  Teeth  and  Stumps. 

Conditions  necessitating  Extraction.  General  Directions  as 
to  the  position  of  Operator  and  Patient.  Concerning  the 
application  of  Forceps.  As  to  the  Extraction  of  the 
Tooth.  Accidents  during  Extraction.  A  list  of  Instru- 
ments needed  for  Extraction.  Forceps,  their  General 
Characters  and  Various  Forms.  The  Elevator,  its  De- 
scription and  Mode  of  Using.     The  Screw  Extractor       .    57 

CHAPTER  IX. 

Anesthetics.     Preparation    of  the   Mouth   for   Frames. 
Salivary  Calculus 75 


LIST   OF    ILLUSTRATIONS. 


Fig.  1. — Diagram  from  a  cast  of  the  upper  jaw  of  a  neglected 

mouth  in  a  child  aged  eight         ....       3 

„    2. — At  the   age  of  three  years   showing   the  ten  upper 

temporary  teeth  .......        7 

,,    3. — At  the   age  of  seven  years,  showing  the  ten  tempo- 
rary teeth  and  also  the  two  six-year-old  molars  .       8 
,,    4. — At  the  age  of  thirteen  years,  showing  the  fourteen 

upper  permanent  teeth         .....       9 

,,    5. — Diagram  of  lower  jaw,  showing  retention  of  tempo- 
rary molar  .         .         .         .         .         .         .         .11 

,,    6. — Diagram  of  a  mouth  showing  supernumerary  teeth 

displacing  incisors       .         .         .         .         .         .11 

„    7. — Malformed  Incisor  ......     12 

,,    8. — Two  lower  temporary  incisors  united  by  cementum     12 
,,    9. — Syphilitic  Incisors  .         .         .         .         .         .         .13 

„    10. —  Honey-combed  Incisors         .         .         .         .         .13 

„    11. — Regulating    Plate    for    treatment    of    irregularity 

among  the  upper  front  teeth         .         .         .         .17 

„    12. — Model  of  upper  jaw  with  rotated  incisors        .         .     19 
,,    13. — Model  of  upper  jaw  with  widely  spaced  and  diver- 
gent incisors        .......     20 

„    14. — Model  of  jaw  with  projecting  canines    .         .         .21 
„    15. — Model  of  a  V-shaped  upper  jaw    .         .         .         .22 

„    16. — Excavator    ........     24 

.,    17. — Mouth  Mirror 25 


Xll  LIST    OF    ILLUSTRATIONS. 


PAGE 


FIG.  18. — Nerve  Extractor  for  removing  devitalized   dental 

nerve  ........     38 

19. — Upper  incisor  and  canine  forceps  .         .         .         .66 

20. — Upper  bicuspid  forceps  for  either  side    .         .         .67 
21. — Forceps  for  lower  incisors,  canines  and  bicuspids    .     68 
22. — Forceps  for  upper  right  molars       .         .         .         ,69 
23. — Forceps  for  upper  left  molars         .         .         .         .70 

24. — Lower  molar  forceps  for  either  side  of  the  mouth  .     70 
25. — Upper  stump  forceps     ......     71 

26. — Lower  stump  forceps     .         .         .         .         .         .71 

27. — Elevator — front  view     ......     73 

28. — Elevator — side  view 73 

29. — Screw  extractor  for  removal  of  stumps  of  upper 

incisors  and  canines 74 

30. — Telescopic  gag  or  mouth  prop,  for  use  during  in- 
halation of  nitrous  oxide      76 

31. — Mouth  opener,  to  be  used  with  the  administration 

of  chloroform .     77 


ERRATUM. 

Page  45,  line  3  from  bottom,  and  page  56,  last  line, 
for  Rhizodon trophy  read  Rhizodontropy. 


DENTAL  SURGERY. 


Chaptek  I. 

THE   FIBST   DENTITION. 

Eruption  of  Temporary  Teeth.  Lancing  the  Gums. 
Absorption  of  Temporary  Fangs.  When  to  Extract 
Temporary  Teeth  for  relief  of  Irregularity. 
Undesirability  of  Extracting  Temporary  Teeth. 
Ulceration  through  the  Gums  of  Temporary  Fangs. 

The  temporary  teeth  are  twenty  in  number,  and  their 
eruption  usually  begins  and  ends  between  the  ages  of  six 
months  and  two  and  a  half  years.  The  following  table 
gives  the  order  and  times  of  cutting  of  the  various  mem- 
bers of  this  series. 

The  2  Lower  Central  Incisors,  about  6th  Month. 


„    2  Upper        ,,             ,, 

„     8th       „ 

,,    2  Lower  Lateral        ,, 

„  10th       „ 

„    2  Upper 

„  12th       „ 

,,    4  1st    Molars 

...     „  16th       „ 

,,    4  Canines 

...     „  20th       ,, 

,,    4  2nd  Molars 

...     „  30th       ,, 

The  protrusion  of  the  tough  unyielding  gum  by  a  grow- 
ing tooth  is  apt  at  times  to  be  attended  with  much  suffer- 


2  DENTAL    SURGERY    FOR 

ing,  evinced  by  a  greatly  increased  flow  of  saliva,  with  febrile 
symptoms  and  convulsive  movements.  Belief  may  be 
then  afforded  by  passing  a  well  protected  lancet  through 
the  whitened  nodule  of  gum  down  to  the  erupting  crown. 
Such  an  operation  should,  however,  be  performed  only 
when  the  mucous  membrane  of  the  mouth  is  in  a  healthy 
condition,  and  when  also  it  is  quite  evident  to  the  sense  of 
touch,  that  the  cutting  edge  of  the  new  tooth  is  bound 
down  by  the  tense  and  fibrous  gum. 

At  the  age  of  four  years  absorption  of  the  fangs  of  the 
temporary  teeth  commences  and  those  of  the  incisors  are 
first  attacked.  This  process,  in  its  nature  purely  vital  and 
in  no  way  mechanical,  is  brought  about  by  the  action  of 
the  Absorptive  Papilla,  a  mass  of  many  nucleated  cells  that 
lies  closely  behind  and  eating  into  each  temporary  fang, 
and  intervening  between  the  latter  and  the  crown  of  its 
permanent  successor. 

A  growing  permanent  tooth  is  placed  immediately  behind 
and  beloiv  the  fang  of  each  temporary  incisor  and  canine, 
while  underneath  each  temporary  molar,  and  embraced 
within  its  widely  diverging  fangs,  is  the  crown  of  the 
bicuspid  that  is  to  take  its  place.  A  knowledge  of  the 
latter  fact  is  of  value  when  it  becomes  necessary  to  extract 
a  temporary  molar,  and  the  forceps  should  then  be  applied 
with  caution  and  not  thrust  deeply  into  the  alveolus,  lest 
the  permanent  be  taken  out  with  the  temporary  tooth. 

It  is  not  often  necessary  to  extract  a  temporary  tooth  to 
make  room  for  its  permanent  successor,  since  the  rapid 
development  of  the  jaw  and  consequent  expansion  of  the 
alveolar  arch  that  occurs  during  childhood  tends  to  per- 


GENERAL    PRACTITIONERS.  3 

mit  permanent  teeth  to  fall  into  their  normal  situations,  al- 
though at  the  time  of,  and  shortly  after  their  eruption,  they 
may  have  been  crowded  out  of  line.  Under  these  circum- 
stances, however,  the  extraction  of  a  temporary  tooth  for 
the  relief  of  irregularity  may  become  necessary.  If  such  a 
tooth  or  its  decayed  fang  be  retained  considerably  after 
the  time  at  which  it  should  normally  be  shed,  while  an  un- 
usual degree  of  fixity  in  its  socket  shows  that  the  action  of 
the  Absorptive  Papilla  upon  its  fang  has  been  but  slight ; 
if  also  the  eruption  of  the  crown  of  its  permanent  successor 
has  well  advanced,  while  the  line  in  which  the  latter  is 
growing  diverges  considerably  from  its  normal  direction ; 
if  these  conditions  be  present  the  obstructing  temporary 
tooth  may  with  advantage  be  removed.  It  becomes  quite 
necessary  that  this  should  be  done  when  the  irregularity 

Fig.  1. 


Diagram  from  a  cast  of  the  upper  jaw  of  a  neglected  mouth  iu  a  child 
aged  eight.  The  four  permanent  incisors  have  erupted,  so  that  they  bite 
within  and  behind  the  lower  teeth  when  the  mouth  is  closed.  The  four 
temporary  are  unduly  retained  with  their  fangs  but  slightly  absorbed. 

b2 


4  DENTAL    SURGERY    FOR 

occurs  among  the  upper  front  teeth,  for  if  a  permanent 
Upper  Incisor  or  Canine  be  allowed  to  grow  so  irregularly 
that  when  fully  erupted  it  bites  behind  the  lower  teeth,  it 
becomes  necessary  to  adopt  a  course  of  tedious  dental 
treatment  that  might  have  been  avoided  by  a  timely  re- 
moval of  a  temporary  tooth. 

The  temporary  molars  are  prone  to  early  and  rapid  de- 
cay ;  their  dental  pulps  are  large,  highly  sensitive,  and 
ready,  as  the  result  of  such  quickly  advancing  caries,  to 
take  on  a  j)rocess  of  destructive  inflammation,  thus  becom- 
ing rapidly  devitalized  and  decomposed.  The  treatment, 
however,  of  decay  with  its  sequelae  among  temporary  and 
permanent  teeth  must  be  referred  to  later  on.  Suffice  it 
now  to  say  that  a  badly  developed  and  carious  set  of  per- 
manent teeth  does  in  no  way  necessarily  occur  in  a  mouth 
which  may  have  been  conspicuous  by  the  faulty  character 
of  its  milk  teeth.  Also  it  should  be  noted  that  temporary 
molars  should  never  be  extracted  save  as  a  last  resource 
and  when  every  attempt  to  relieve  pain  by  other  means 
has  failed.  Small  cavities  occurring  in  them,  should  if 
possible  be  filled  before  decay  has  encroached  greatly  upon 
their  walls,  and  in  so  doing  it  is  well  always  to  avoid  caus- 
ing pain  to  the  child.  Carious  dentine  and  enamel 
should  be  very  lightly  removed,  and  for  the  stopping  of  the 
cavity  such  a  material  as  gutta-percha  gently  warmed 
over  a  candle  flame,  or  cotton  wool  that  has  been  dipped 
into  a  solution  of  gum  mastic  in  alcohol,  answers  admir- 
ably. Decay  when  more  advanced,  with  death  of  the  pulp 
resulting,  may  necessitate  other  treatment;  but  always  this 
should   be  remembered,   that  a  broken  down  temporary 


GENERAL    PRACTITIONERS.  5 

molar,  if  only  it  be  not  causing  pain,  is  better  than  none 
at  all  and  may  be  invaluable  to  the  child  for  the  mastica- 
tion of  its  food  and  the  due  nutrition  of  its  body. 

It  has  been  said  that  it  is  occasionally  necessary  to  ex- 
tract temporary  teeth  to  prevent  irregularity.  Under  these 
conditions  also  they  may  require  to  be  removed  ;  when  as 
the  result  of  the  absorption  of  the  posterior  surfaces  of  their 
fangs,  the  sharp  ragged  ends  so  resulting  have  ulcerated 
through  the  gum  and  have  wounded  the  lip  or  cheek. 
The  laceration  and  inflammation  of  the  soft  parts  is  apt 
to  be  more  severe  when  it  results  from  a  lower  than  when 
caused  by  an  upper  fang,  owing  to  the  greater  mobility  of 
the  tissues  around  the  former.  The  trouble  of  course 
ceases  as  soon  as  the  cause  is  recognised  and  removed,  but 
the  condition  should  be  carefully  noted,  lest  it  be  wrongly 
attributed  to  necrosis  and  exfoliation  of  a  portion  of  the 
maxilla. 


DENTAL    SURGERY    FOR 


Chaptek  II. 
THE    SECOND  DENTITION. 

Order  of  Ekuption  of  Permanent  Teeth.  Eruption  of 
Wisdom  Teeth.  Diagrams  of  Teeth  at  Three 
Periods  of  Childhood.  How  to  distinguish  between 
Temporary  and  Permanent  Teeth. 

The  order  and  times  of  eruption  of  the  permanent  teeth 
are  as  follows  : — 

The  4  1st  Molars  at  about  the    6th  year. 

,,  2  Lower  Central  Incisors 

,,  2  Upper 

,,  4  Lateral  Incisors 

,,  4  1st  Bicuspids 

„  4  2nd 

„  4  Canines 

,,  4  2nd  Molars 

„  4  3rd  Molars 

As  a  rule  but  little  local  or  general  disturbance  attends 
the  eruption  of  the  permanent  teeth.  They  grow  up  be- 
hind their  temporary  predecessors  which  in  due  course 
become  loosened  and  are  shed.  And  thus  the  process  is 
quietly  effected  without  attracting  much  notice. 

The  cutting  of  the  lower  wisdom  tooth  is  often,  however, 


71                     5) 

??                     7 

8th     , 

?»                     ? 

9th     , 

73                     3 

10th     , 

33                      7 

11th     , 

77                     3 

,     12th     , 

73                     7 

,     13th     , 

73                     3 

,     20th     , 

GENERAL    PRACTITIONERS.  7 

attended  with  a  good  deal  of  suffering.  A  flap  of  gum  is 
lifted  up  by  its  growing  crown  and  between  this  last  and 
the  upper  second  molar  the  gum  structure  is  liable  to  be 
bruised  during  mastication.  Belief  may  at  times  be  given 
by  incising  the  constricting  tissue  and  by  touching  the  in- 
cised surface  lightly  with  nitrate  of  silver.  Usually  the 
pain  and  inflammation  subside  in  the  course  of  a  few  days, 
and  the  treatment  of  such  cases  may  generally  be  limited 
to  the  use  of  hot  fomentations  inside  the  mouth.  If,  how- 
ever, the  erupting  third  molar  be  impacted  between  the  base 
of  the  coronoid  process  and  the  back  of  the  second  molar  its 

Fig.  2. 


At  the  age  of  three  years  showing  the  ten  upper  temporary  teeth. 

Two  Temporary  Central  Incisors. 
,,  ,,         Lateral       „ 

,,  ,,  Canines. 

,,  „         1st  Molars. 

,,  ,,         2nd  Molars. 


extraction  may  become  necessary,  and  if  this  be  found  to 
be  quite  impracticable  it  may  be  needful  to  remove  the 
second  molar  to  give  relief.     It  should  of  course  be  borne 


8 


DENTAL    SURGERY    FOR 


in  mind  that  a  second  molar  is  perhaps  more  useful  and 
durable  than  any  other  tooth  in  the  mouth,  so  that  its  ex- 
traction should  be  regarded  as  quite  a  last  resource. 

The  accompanying  diagrams  represent  the  upper  teeth  at 
three  characteristic  periods  of  childhood. 

Fig.  3. 


At  the  age  of  seven  years,  showing  the  ten  above  mentioned  temporary 
teeth,  and  also  the  recently  erupted  1st  permanent  or  six  year  old  molars. 
Two  Temporary  Central  Incisors. 
,,  „         Lateral       „ 

,,  „         Canines. 

„  „         1st  Molars. 

,,  „  2nd  Molars. 

,,      Permanent  1st  Molars. 


The  need  for  being  able  to  decide  on  examining  a  mouth, 
whether  any  given  tooth  be  temporary  or  permanent  is 
evident.  As  a  rule  there  is  no  difficulty  in  so  doing. 
The  permanent  incisors  are  larger  and  more  yellow  in  tint 
than  those  of  the  milk  dentition,  while  their  cutting  edges 
are  serrated  for  a  year  or  two  after  eruption.    Later  on  the 


GENERAL    PRACTITIONERS.  9 

serrations  become  obliterated,  as  occurs  among  young  milk 
teeth  which  are  soon  worn  smooth  by  the  friction  of  eating. 
The  bicuspids  can  not  easily  be  mistaken  for  the  temporary 

Fig.  4. 


At  the  age  of  thirteen  years,  showing  the  fourteen  upper  permanent 
teeth.  All  the  temporary  teeth  have  been  replaced  by  their  ten  corres- 
ponding permanent  ones,  and  also  the  1st  aud  2nd  permanent  molars  have 
been  cut.  The  six  temporary  incisors  and  canines  have  been  replaced  by 
the  six  permanent  incisors  and  canines ;  and  the  four  temporary  molars 
have  been  replaced  by  the  four  bicuspids. 

Two  Permanent  Central  Incisors. 

,,  Lateral       ,, 

,,  Canines. 

,,  1st  Bicuspids. 

,,  2nd  Bicuspids. 

,,  1st  Molars. 

,,  2nd  Molars. 

molars  which  they  replace,  but  it  is  well  to  guard  against 
extracting  a  permanent  canine  tooth  under  the  impression 
that  it  is  the  corresponding  temporary  one,  and  also  the  first 
permanent  molar  should  not  be  mistaken  for  the  second 
temporary  one. 


10  DENTAL    SURGERY    FOR 


Chapter  III. 

ABNORMALITIES    IN    DEVELOPMENT    OF 
PERMANENT  TEETH. 

Retarded  Eruption.  Supernumerary  Teeth.  Abortive 
Teeth.  Dilacerated  and  Geminated  Teeth.  Honey- 
combed and  Syphilitic  Teeth. 

Retarded  eruption. — The  cutting  of  a  permanent  tooth  may 
be  delayed  long  after  the  normal  time,  or  its  absence  may 
continue  through  life.  To  teeth  thus  buried  and  but  partly 
developed  have  been  attributed  myeloid  and  other  growths 
which  have  been  found  within  the  maxillae  in  their  neigh- 
bourhood. Whether  it  be  true  or  not  that  such  tumours 
have  arisen  from  such  causes,  the  author  is  unable  to  say, 
but  he  is  inclined  to  believe  the  dental  irregularity  to  have 
been  merely  a  coincidence  with,  or  even  a  result  of,  the  pro- 
gress of  the  diseased  growth.  At  times  an  incisor  or 
canine  tooth  may  remain  throughout  life  embedded  in  the 
the  palatine  process  of  the  upper  maxilla  or  but  partially 
erupted  from  its  lower  surface.  A  lower  wisdom  tooth 
has  been  removed  from  the  cheek,  near  the  angle  of  the 
jaw,  where  its  late  eruption  caused  much  distress  and 
deformity. 

Irregularity  in  excess  of  the  normal  number. — Such  addi- 
tional teeth  are  Supernumeraries.  They  are  usually  found 
in  the  front  of  the  mouth,  in  the  neighbourhood  of  the  upper 


GENERAL    PRACTITIONERS. 


II 


permanent  incisors,  among  which  by  their  presence  they 
may  cause  a  good  deal  of  irregularity.  Supernumerary 
teeth  are  more  or  less  conical,  with  stunted  fangs.     As  a 

Fig.  5. 


Diagram  of  a  model  of  the  right  side  of  a  lower  jaw  aged  36.  All  the 
lower  permanent  teeth  are  erupted  with  the  exception  of  the  2nd  bicus- 
pid. The  2nd  temporary  molar  is  retained  and  serves  to  illustrate  the 
difference  in  level  between  the  temporary  and  permanent  series. 


Fig  6. 


Diagram  of  a  mouth  aged  13.  In  the  front  of  the  mouth  are  two  super- 
numerary teeth  which  are  displacing  permanent  incisors  from  their 
rightful  positions. 


12  DENTAL    SURGERY    FOR 

rule  it  is  well  to  extract  them,  if  by  their  presence  they  are 
causing  the  normally  developed  teeth  to  take  up  improper 
positions  in  the  dental  arch. 

Abortive  Teeth. — A  tooth  though  normally  placed  in  the 
series  may  be  irregular  in  form.  Annexed  is  a  drawing  of 
a  permanent  central  incisor,  or  of  what  corresponded  there 
with,  which  was  removed  on  account  of  its  deformity  from 
a  patient  in  the  dental  department  of  the  London  Hospital. 

Fig.  7. 


Further  as  the  result  of  developmental  irregularity,  the 
long  axis  of  a  tooth  may  be  bent  at  an  angle  near  its  neck, 
when  it  is  said  to  be  dilacerated.  Also  two  adjacent  teeth 
may  be  geminated,  or  united  by  their  adjacent  surfaces,  the 
union  being  sometimes  so  complete  that  they  have  but  one 
common  pulp  cavity. 

Fig.  8. 


Two  lower  temporary  incisors  united  by 
cementum  on  their  adjacent  sides. 

Certain  structural  defects  may  be  evident  among  all  the 
teeth  of  the  permanent  series. 


GENERAL    PRACTITIONERS.  13 

Honeycombed  or  Strumous  Teeth. — The  incisors  and  first 
molars  most  often  present  the  appearance  of  such.  These 
are  dark-yellow  in  colour  and  deeply  pitted  or  ridged 
transversely  upon  their  surfaces,  as  though  the  deposition 
of  enamel  had  been  injuriously  affected  during  the  develop- 
ment of  the  organs.  The  inheritance  of  a  strumous  dia- 
thesis, or  overdosing  with  mercury  in  early  childhood, 
have  both  been  said  to  have  induced  this  condition,  but  its 
cause  is  still  obscure.  A  careful  distinction  must  be  drawn 
between  this  and  the  following  abnormality. 

Syiihilitic  or  Specifie  Teeth. — These,  the  result  of  inherit- 
ance of  the  syphilitic  taint,  show  the  following  well  marked 
characteristics  :  — One  crescentic  notch  in  the  middle  of  the 
cutting  edges  of  the  upper  and  lower  permanent  incisors. 
These  teeth  are  also  separated  from  each  other  ;  are  of 
dark  colour,  and  of  peg-top  shape.  The  development  of 
the  bicuspids  and  molars  is  also  modified,  but  the  central 
notch  of  the  incisors  is  most  typical  of  the  diathesis.  The 
temporary  teeth  of  children  with  syphilitic  parentage  pre- 
sent no  peculiar  traits.     The  annexed  two  diagrams  are 

Fig.  9.  Fig.  10. 


''iiiu,i;.ii'lwiiiuii'»- 
Syphilitic  Incisors.  Honeycombed  Incisors. 

from  drawings  by  Mr.  Hutchinson,  and  show  the  features 
of  typically  marked  honeycombed  and  syphilitic  permanent 
upper  central  incisor  teeth. 


14  DENTAL    SURGERY    FOR 


Chapter  IV. 

IEKEGULABITY     IN    THE    POSITIONS     OF     THE 
PEKMANENT   TEETH. 

Cause  of  Irregularity  Among  Teeth  of  the  Present 
Time.  Treatment  of  Irregularity  by  Extraction  and 
the  eegulating  plate.  symmetrical  extraction. 
Six  Common  Forms  of  Irregularity  : — 1.  Underhung 
Incisors  ;  2.  Kotated  Incisors  ;  3.  Projecting  and 
Diverging  Incisors  ;  4.  Projecting  Canines  ;  5.  The 
V-shaped  Dental  Arch  ;  6.  Irregular  Articulation 
of  Upper  with  Lower  Teeth.  The  Excavator  and 
the  Mouth  Mirror. 

Irregularity  in  the  arrangement  of  the  permanent  teeth 
is  among  civilized  races  greatly  on  the  increase,  and 
its  cause  may  be  found  in  the  lessened  work  thrown 
up6n  the  organs  of  mastication  by  the  appliances  and 
requirements  of  modern  life,  whence  results  decreased 
development  of  both  teeth  and  jaws.  But  while  the  shape 
size  and  number  of  the  teeth  has  not  undergone  much 
change,  with  the  exception  of  the  wisdom-tooth  which  is 
now  more  variable  and  less  developed  than  in  skulls  of 
earlier  date,  we  find  that  the  development  of  the  maxillary 
bones  is  frequently  far  less  complete  than  in  the  older 
periods  of  man's  history.     So,  with  a  stunted  alveolus  and 


GENERAL    PRACTITIONERS.  15 

teeth  of  normal  size,  overlapping  and  crowding  of  the  latter 
too  often  ensues. 

Such  irregularities  are  so  varied  that  an  altogether  satis- 
factory method  of  classifying  them  is  not  very  practicable. 
The  common  and  typical  deformities  are  therefore  only 
described  and  it  must  be  noted  that  any  one  may  co- exist 
with  other  forms.  Irregular  and  overlapping  teeth  when 
occurring  in  the  front  of  the  upper  jaw  are  more  unsightly 
than  when  they  are  found  in  the  lower,  but  under  all  cir- 
cumstances it  is  desirable  that  the  teeth  should  be  evenly 
arranged  in  the  maxillae.  Behind  projections  and  between 
overlapping  teeth  the  food  that  always  collects  and  is  apt 
to  escape  the  cleansing  action  of  the  tooth  brush  will  cer- 
tainly decompose  and  thus  favour  the  attack  of  caries. 

For  the  curing  of  irregularity,  we  have  two  methods  of 
treatment  which  may  be  applied  singly  or  combined  ;  we 
may  extract  teeth  to  give  additional  room,  or  we  may  em- 
ploy a  regulating  plate  to  produce  a  like  effect  by  forcing 
the  teeth  outwards  and  so  expanding  the  dental  arch.  If 
extraction  alone  be  practised  these  points  should  be  noted. 
The  front  teeth,  and  especially  the  canines,  should  if  possible 
be  spared,  since  the  loss  of  the  two  upper  eye  teeth  is  apt  to 
alter  the  appearance  of  the  face  by  the  considerable  absorp- 
tion of  alveolar  process  that  follows  their  extraction  and 
the  consequent  sinking  in  of  the  angle  of  the  mouth.  The 
canines  moreover  have  more  value  for  purposes  of  mastica- 
tion than  other  front  teeth,  since  they  are  less  liable  to  decay 
and  are  more  firmly  implanted  in  the  alveolar  sockets. 
Before  deciding  which  teeth  may  best  be  spared  careful  ex- 
amination of  the  mouth  with  the  assistance  of  a  fine  exca- 
vator and  a  mouth  mirror  should  be  made. 


l6  DENTAL    SURGERY    FOR 

If  all  bicuspids  and  molars  be  well  developed  and  free 
from  decay  then  the  best  and  speediest  mode  of  curing  the 
irregularity  may  be  by  the  removal  of  the  two  upper  and 
possibly  also  of  the  two  lower  first  bicuspids.  But  if  as  is 
more  likely  to  be  the  case,  decay  be  present  among  the 
first  permanent  molars,  two  or  four  of  these  should  be  ex- 
tracted. It  is  upon  these  teeth  that  the  choice  will  pro- 
bably fall  since,  from  a  cause  that  has  not  yet  been 
ascertained,  dental  decay  is  more  prevalent  and  commences 
earlier  among  the  first  molars  than  among  other  teeth. 

Such  extraction  should  be  practised  symmetrically.  If 
an  upper  molar  or  bicuspid  on  one  side  be  removed,  then 
also  the  corresponding  tooth  on  the  other  side  of  the  mouth 
should  be  taken  out ;  or  if  of  the  four  six-year-old  molars,  or 
of  the  four  1st  bicuspids,  two  only,  an  upper  on  the  right  and 
a  lower  on  the  left,  be  decayed,  or  if  three  of  the  series  be 
carious  and  the  other  sound,  then  the  extraction  should  be 
completed  as  regards  all  four  corresponding  teeth.  Thus 
from  a  timely  and  judicious  symmetrical  extraction  will  often 
follow  a  natural  and  symmetrical  regulation  of  the  crowded 
front  teeth,  and  the  forces  tending  to  bring  this  about  are 
the  continuous  pressure  exerted  upon  the  dental  arches 
by  the  lips  and  muscles  of  the  face  and  the  tongue. 

If  then  it  be  advised  to  part  with  four  1st  molars,  the  time 
most  suited  for  such  extraction  is  that  at  which  the  four 
2nd,  or  12-year-old,  molars  are  just  erupting.  The  latter 
then  advance  and  in  two  years  time  the  spaces  resulting 
from  extraction  are  nearly  obliterated.  Although  the  re- 
moval of  four  decayed  first  molars  may  hardly  serve  of  it- 
self to  materially  alter  the  positions  of  much  overlapping 


GENERAL    PRACTITIONERS. 


17 


front  teeth,  yet  the  additional  room  thus  gained  in  the 
mouth  can  not  but  be  salutary,  since  the  increase  of  the 
irregularity  from  the  pressing  forward  of  erupting  and  ad- 
vancing back  teeth  is  certainly  arrested.  Also  the  more 
perfect  cleansing  and  polishing  of  the  sides  of  bicuspids  and 
molars  which  is  rendered  practicable  by  the  slight  separa- 
tion that  ensues  among  them  conduces  very  greatly  to 
their  ultimate  preservation  from  caries. 

The  regulating  plate,  usually  of  vulcanite  or  gold,  is  con- 
structed by  the  dentist  to  a  plaster  model  of  the  jaw  with 
its  contained  irregular  teeth.  Such  a  plate  carries  elastic 
gold  wires  which  looping  over  the  outstanding  teeth  serve 
to  draw  them  back  into  line,  and  also  if  needed  it  may  con- 
tain small  wooden  pegs  to  press  upon  the  posterior  surfaces 

Fig.  11. 


Vulcanite  regulating  plate  for  treatment  of  irregularity  among  the  upper 
front  teeth,  showing  the  gold  wires  and  wooden  pegs  referred  to. 

of  back-standing  teeth.  Thus  by  the  forcing  of  these  out- 
wards the  dental  arch  is  expanded  and  increased  room  ob- 
tained for  the  reduction  of  any  irregularity. 

c 


l8  DENTAL    SURGERY    FOR 

During  the  wearing  of  all  regulating  plates  great  cleanli- 
ness should  be  observed ;  the  teeth  being  brushed  with 
soap  and  water  each  morning  and  evening,  and  the  plate 
being  taken  from  the  mouth  after  every  meal  to  be  brushed 
in  like  manner  on  both  surfaces.  If  this  be  done  a  regu- 
lating plate  may  be  safely  worn  for  several  months,  but  if 
it  be  omitted  the  acid  produced  by  decomposition  of  food 
and  saliva  will  shortly  soften  and  erode  the  crowns  of  the 
teeth. 

The  irregularities  most  often  met  with  are  as  follows  : — 
1.  One  or  more  permanent  incisors  may  be  erupted  con- 
siderably behind  the  line  of  their  neighbours,  as  the  result 
of  undue  retention  of  temporary  teeth  (vide  fig.  1,  Chap.  I). 
This  may  be  prevented  by  the  judicious  removal  of  the  latter 
when  required,  but  if  the  abnormality  happen  to  upper  front 
teeth  these  may  be  found  to  be  underhung,  or  to  bite  be- 
hind the  lower  incisors  when  the  jaws  are  closed.  In 
this  last  case  a  regulating  plate  (vide  fig.  11)  mus  be  worn 
for  three  or  four  weeks,  which  shall  force  out  with  the  aid 
of  steel  screws,  or  a  series  of  wooden  pegs  each  longer  than 
its  predecessor,  the  back- standing  tooth  or  teeth.  That  this 
may  be  effected  the  jaws  must  be  kept  a  little  apart  by 
carrying  the  vulcanite  plate  over  the  masticating  surface 
of  the  molars  and  bicuspids,  and  but  a  short  course  of  such 
treatment  will  be  needed  to  push  forward,  the  back- standing 
upper  incisor,  so  that  its  lower  antagonist  shall  close  be- 
hind rather  than,  as  was  the  case  before  treatment  com- 
menced, in  front  of  it.  As  soon  as  this  changed  condition 
is  brought  about  the  regulating  frame  may  be  left  off, 
since  the  misplaced  tooth  cannot  relapse  into  its  old  posi- 


GENERAL    PRACTITIONERS. 


19 


tion,  and  the  closure  of  the  lower  jaw  upon  the  upper  will 
shortly  induce  a  symmetrical  arrangement  of  the  upper 
front  teeth. 

2.  An  incisor  tooth  may  be  partly  rotated  on  its  long 
axis  (videftg.  12).  This  should  be  treated  with  a  regulating 
plate  constructed  to  draw  back,  by  the  aid  of  a  gold  wire,  the 
projecting  margin,  and  with  a  wooden  peg  to  push  out  the 
side  of  the  tooth  that  is  so  rotated  inwards.  A  few  years 
back  it  was  not  unusual  to  forcibly  turn  such  teeth  into 
proper  position  with  the  aid  of  forceps.  This  course  is 
not  to  be  recommended,  as  the  disruption  that  it  causes  to 
the  nerves  and  vessels  entering  the  tooth  at  the  end  of  its 
fang  is  very  liable  to  induce  death  and  early  loss  of  the 
organ. 

Fig.  12. 


Model  of  upper  jaw  with  rotated  incisors. 

3.  The  upper  incisor  teeth  may  be  widely  spaced  and 
divergent  (vide  fig.  13).  Such  cases  are  best  treated  by 
the  dental  surgeon,  who,  if  there  be  no  obstacle  to  regu- 
lation, such  as  a  pressure  upon  then  back  surfaces  of  the 
lower  incisors,  may  draw  in  two  divergent  centrals  by 
j)lacing  around  their  necks  a  thin  elastic  band.  It  must 
be  noted  that  such  treatment  needs  close  watching,  and 

c2 


20 


DENTAL    SURGERY    FOR 


the  band  must  be  prevented  from  forcing  itself  up  the 
necks  of  the  teeth  beneath  the  gum  by  attaching  to  it  one 
or  more  gold  wire  loops,  which  may  be  hooked  over  the 
cutting  edges  of  the  teeth  that  are  being  operated  upon. 
If  this  be  neglected  the  latter  will  certainly  be  loosened 
and  will  probably  be  lost. 


Model  of  upper  teeth  with  widely  spaced  and  divergent  incisors. 

4.  The  canines  may  greatly  project  while  the  incisors  are 
overlapping  (vide  fig.  14).  This  is  a  very  common  form  of 
irregularity,  and  is  doubtless  favoured  by  the  later  eruption 
of  the  eye-teeth,  as  compared  with  that  of  the  incisors  and 
bicuspids,  whereby  the  former  find  the  spaces  into  which 
they  should  normally  fall  in  the  dental  arch  closed  to  their 
admission  by  the  approximation  of  the  lateral  incisors  with 
the  first  bicuspids.  In  such  an  irregularity  much  improve- 
ment may  be  hoped  for  with  time  and  during  that  growth 
and  expansion  of  the  maxillse  which  continues  for  a  few 
years  after  the  canines  are  erupted.  Should  this,  however, 
seem  insufficient  to  provide  such  space  as  may  be  required 
by  the  projecting  eye-teeth  it  will  be  necessary  to  extract 


GENERAL    PRACTITIONERS. 


21 


first  bicuspids,  and  into  the  gaps  caused  by  their  removal 
the  former  will  in  all  probability  be  conducted  by  the 
gentle  but  continuous  pressure  upon  then  outer  surfaces 
of  the  muscles  of  the  lips  and  cheeks.  More  complete 
symmetry  may  with  certainty  be  given  to  the  dental 
arch  if,  in  addition  to  extraction  of  bicuspids,  a  vulca- 
nite regulating  plate  be  employed  for  a  few  weeks  to 
draw  back  the  canines,  and  at  the  same  time  to  push 
out  into  a  symmetrical  curve  the  irregular  and  crowded 
incisor  teeth. 

Fig.   14. 


Model  of  upper  jaw,  aged  14  years.  The  canines  are  projecting  but 
these  were  subsequently  drawn  backwards  and  inwards  by  a  dental  plate 
into  the  spaces  caused  by  the  removal  of  the  first  bicuspids.  At  the 
same  time  the  four  incisors  were  pushed  slightly  outwards  by  wooden 
pegs  connected  with  the  frame.  The  model  was  taken  a  month  after  re- 
moval of  the  two  1st  bicuspids. 

5.  A  V-shaped  dental  arch  may  be  combined  with  a 
deeply  vaulted  palate  {vide  fig.  15),  and  this  form  of  irregu- 
larity is  often  associated  with  congenital  idiocy.    The  upper 


22  DENTAL    SURGERY    FOR 

teeth  are  here  found  to  be  arranged  along  two  more  or  less 
straight  lines  converging  towards  and  meeting  at  the  front 
of  the  mouth.  Treatment  should  go  in  the  direction  of 
expanding  the  arch  by  regulating  plates,  and  of  gaining 
additional  room  by  a  judicious  thinning  out  of  bicuspids 
or  first  molars. 

Fig.  15. 


Model  of  a  V-shaped   upper  jaw.     This  was   co-existing  with  a  vaulted 
palate  and  idiocy  of  a  congenital  nature. 

The  V-shaped  arch,  and  the  form  of  irregularity  to  be 
next  described,  are  frequently  transmitted  by  inheritance, 
and  it  is  not  unusual  to  find  a  like  defect  among  all  the 
children  of  parents  presenting  either  of  these  deformities. 
It  cannot  be  disputed  that  such  errors  in  maxillary  develop- 
ment are  infinitely  more  frequent  among  civilized  than 
among  savage  races,  and  though  the  V-shaped  arch  and  a 
deeply  vaulted  palate  may  co-exist  with  well  developed 
cerebral  organs,  yet,  as  Dr.  Langdon  Down  has  pointed  out, 
(Transactions  of  Odontological  Society,  1871),  it  is  extremely 


GENERAL    PRACTITIONERS.  2$ 

common  to  find  such  well  marked  defects  in  the  mouths  of 
congenital  idiots,  and  this,  as  the  same  authority  ha-  si  :  i, 
possesses  practical  value.  Given  a  V-shaped  arch  and 
vaulted  palate  in  the  mouth  of  an  idiot,  we  may  assume  that 
the  defective  development  in  mouth  and  brain  results  from 
a  cause  which  acted  prior  to  the  birth  of  the  patient ;  that 
the  idiocy  was  congenital.  If,  on  the  other  hand,  a  nor- 
mally developed  mouth  co-exist  with  idiocy  it  is  probable 
that  the  latter  was  acquired  after  birth.  Concerning  the 
treatment  of  the  former  a  more  favourable  prognosis 
may  be  given,  since  a  brain  imperfectly  developed  is  more 
amenable  to  treatment  than  one  whose  functions  have  been 
impaired  by  some  grave  lesion  induced  after  birth. 

6.  In  a  less  common  fomi  of  irregularity,  which  like  the 
Y-shaped  arch  is  frequently  hereditary,  we  find  the  cutting 
edges  of  the  lower  incisors  set  at  a  level  higher  than  that  of 
the  grinding  surfaces  of  the  lower  bicuspids  and  molars. 
Ab  a  result  of  this  the  upper  incisors  are  gradually  bitten 
out  and  loosened  by  the  pressure  upon  their  backs  of  the 
lower  teeth  whenever  the  jaws  are  closed. 

In  a  case  such  as  this.  lately  under  treatment,  the  only 
plan  that  promised  ultimately  to  be  successful  in  prevent- 
ing the  loss  of  the  two  upper  central  incisors  was  to  adapt 
a  thin  gold  plate  to  the  grinding  surfaces  of  the  lower  masti- 
cating teeth,  and  thus  the  lower  front  teeth  were  kept  out 
of  reach  of  the  upper  ones  which  they  were  rapidly  destroy- 
ing. Before  the  wearing  of  this  plate,  which  served  only  to 
prevent  increase  in  the  irregularity  and  in  no  way  tended 
to  reduce  it.  a  prolonged  but  quite  unsuccessful  attempt  to 
improve  the  positions  of  the  upper  and  lower  teeth  had 


24  DENTAL    SURGERY    FOR 

been  made.  The  four  first  bicuspids  had  been  removed ; 
the  lower  incisors  had  been  slightly  shortened  by  filing 
away  a  little  from  their  cutting  edges  ;  the  lower  incisors 
with  the  lower  canines  had  been  drawn  back  by  a  vulcanite 
regulating  plate ;  this  being  effected,  the  projecting  upper 
incisors  and  canines  were  then  drawn  in  by  the  continuous 
and  gentle  contraction  of  an  elastic  band  passed  round  the 
back  of  the  head  and  attached  to  each  end  of  a  narrow 
gold  band  that  impinged  upon  the  front  surfaces  of  the 
six  projecting  upper  front  teeth.  By  this  prolonged 
treatment  the  irregularity  was  almost  entirely  cured, 
but  on  discontinuing  the  apparatus  the  case  unfortu- 
nately relapsed  into  something  much  like  its  first  con- 
dition, through  the  renewed  pressure  upon  the  backs  of 
the  upper  front  teeth  of  the  cutting  edges  of  the  lower 
ones.  From  this  it  may  be  inferred  that  malformations  of 
this  nature  are  less  amenable  to  treatment  than  those  spoken 
of  before. 

Fig.  16. 


An  excavator  for  use  in  examination  of  teeth  and  preparation 

of  cavities. 

The  Excavator  (videfLg.  16)  should  be  strong  and  well  tem- 
pered, so  that  it  may  neither  readily  bend  nor  break.  While 
the  operator  is  conveying  it  towards  the  patient's  face  and 
into  his  mouth,  its  cutting  edge  should  be  pressed  firmly 
against  the  end  of  the  second  finger,  that  there  may  be  no 
chance  of  wounding  either  face  or  eyes  by  any  incautious 


GENERAL    PRACTITIONERS.  25 

movement  on  the  part  of  the  patient.  The  excavator  may 
be  used  as  a  probe  to  search  for  half  concealed  stumps,  or 
to  explore  a  cavity  in  a  carious  tooth.      In   doing  the  last 

Fig.  17. 


A  mouth  mirror  for  use  in  examination  of  the  teeth. 

guard  against  wounding  a  sensitive  dental  pulp  and  so  in- 
flicting much  unnecessary  pain.  Also  the  excavator  may 
be  employed  to  prepare  a  cavity  for  the  reception   of  a 


26  DENTAL    SURGERY    FOR 

gutta-percha  or  other  stopping  by  cutting  away  softened 
and  decayed  tooth  structure.  It  may  be  used  to  carry  into 
the  mouth  a  dressing  of  absorbent  wool,  which  may  be  used 
as  a  mop  to  remove  blood  or  saliva  from  the  part  to  be 
operated  upon.  Also  the  excavator  is  of  great  value  in 
enabling  us  to  learn  if  the  tooth  to  be  extracted  is  rigidly 
implanted  in  the  maxilla  or  is  at  all  moveable.  When  used 
thus,  the  instrument,  which  should  be  a  specially  strong 
one,  should  rest  upon  a  solid  part  of  the  crown  of  the  tooth, 
and  thus,  with  a  very  small  amount  of  force,  most  teeth 
may  be  slightly  moved  laterally  to  and  fro.  Such  mobility 
may  teach  the  operator  that  no  special  difficulty  is  to  be 
expected  in  the  removal  of  the  tooth  ;  but  if  the  latter  be 
glued  down  into  its  socket  by  inflammatory  exudation,  or  if 
its  fangs  be  solidly  implanted  in  a  massive  and  unyielding 
maxilla,  we  shall  not  succeed  in  producing  any  movement 
of  its  crown  by  manipulation  with  the  excavator. 

The  Mouth  Mirror  (vide  fig.  17)  is  of  value  when  it  is 
desired  to  reflect  a  ray  of  light  upon  some  obscure  situa- 
tion in  the  mouth,  and  also  for  showing  cavities  in  the 
backs  of  molar  teeth.  It  is  well  before  its  use  to  slightly 
warm  it  in  hot  water,  or  over  the  lamp,  in  order  that  its 
face  may  not  be  clouded  by  moisture  condensed  from  the 
breath. 


GENERAL    PRACTITIONERS.  27 


Chapter  Y. 
DENTAL   CAEIES. 

Tendency  of  Teeth  to  Become  Kudimentary.  Local  and 
General  Causes  of  Decay.  Two  Varieties  of  Caries. 
Liability  of  Various  Teeth  to  Decay.  General 
Directions  as  to  Treatment  of  Caries.  Symptoms 
and  Treatment  of  Caries  in  its  First  Stage.  Caries 
in  its  Second  Stage,  with  Antiseptic  Treatment  of 
the  Pulp  Cavity  and  Symptoms  and  Treatment  of 
Periodontitis  and  Alveolar  Abscess.  Caries  in  its 
Third  Stage,  with  Contraction  of  Temporo- Maxillary 
Articulation  and  Fistulous  Opening  Through  Cheek. 

Dental  decay  is  far  more  prevalent  among  the  civilized 
races  of  the  present  day  than  among  the  aboriginal  tribes 
of  Africa,  America,  and  Australia  ;  also  an  examination  of 
ancient  skulls  proves  it  to  be  one  of  the  incidents  of  advanc- 
ing civilization.  This  is  the  outcome  of  several  causes  : 
such  as  the  preservation  of  the  weakly  and  their  greater  re- 
production that  now  obtains ;  the  general  lessening  of  bodily 
vigour  and  development  that  is  apt  to  go  with  increased  men- 
tal cultivation  ;  and  the  smaller  need  for  dental  organs  that 
comes  from  improvement  in  the  quality  and  preparation  of 
modern  food.  It  is  perhaps  not  easy  to  say  what  degree 
of  value  should  be  set  upon  this  last,  but  certain  it  is  that 
the  teeth  and  jaws  of  to-day  have  far  less  work  thrown  upon 
them  than  in  times  when  man  lived  upon  roots  and  imper- 


28  DENTAL    SURGERY    FOR 

fectly  prepared  coarse  flesh,  and  we  may  assume  that  the 
development  of  the  teeth,  as  of  other  organs,  varies  with  the 
amount  of  labour  they  are  called  upon  to  perform.  The 
frequent  absence  of  one  or  more  third  molars,  their  often 
late  eruption,  and  their  commonly  dwarfed  size ;  the  in- 
crease of  dental  caries  ;  and  the  tendency  to  early  shedding 
of  the  teeth  from  absorption  of  their  alveolar  sockets,  all 
suggest  that  the  dental  organs  of  civilized  man  are  tending 
to  become  rudimentary. 

The  local  conditions  predisposing  to  decay  are  twofold ; 
defective  development  of  dentine  and  enamel,  and  abrasion 
and  crushing  of  the  latter  from  overcrowding  of  the  teeth. 
If  either  condition  be  present  the  tooth,  like  a  badly  built 
house,  admits  moisture  into  its  interior.  The  evidence  of 
defective  development  may  be  found  in  those  linear  cracks 
between  the  cusps  of  molars  and  bicuspids,  or  uj>on  the 
back  surfaces  of  upper  lateral  incisors,  which  a  careful 
scrutiny  will  often  reveal  shortly  after  their  eruption. 
The  abrasion  of  enamel  which  favours  decay  occurs  in 
crowded  mouths  upon  the  lateral  surfaces  of  bicuspids, 
which  by  their  slight  mobility  during  mastication  are  ren- 
dered liable  to  such  injury.  With  such  defects  present  in 
the  structure  of  a  tooth  it  is  certain  that  saliva  and  debris 
of  food  will  find  their  way  into  its  interior,  there  to  decom- 
pose and  generate  those  acids  which  serve  to  dissolve  out 
its  lime  salts.  Dental  decay  consists  essentially  in  the 
solution  and  separation  of  the  earthy  or  inorganic  salts  of 
a  tooth,  from  its  animal  matrix,  and  chiefly  of  this  last 
does  carious  dentine  consist.  The  reaction  of  the  latter  is 
markedly  acid  to  litmus  paper,  and  microscopic  examina- 


GENERAL    PRACTITIONERS.  20, 

tion  reveals  upon  its  surface,  and  within  its  tissue,  a  copi- 
ous development  of  the  cryptogam,  Leptothryx  Buccalis, 
the  sporules  of  which  penetrate  into  and  between  the  den- 
tinal tubules.  Although  the  existence  of  this  is  perhaps 
not  essential  to  decay,  since  a  healthy  tooth  may  be  decal- 
cified by  immersion  in  acetic  acid,  yet  we  may  believe  that 
the  growth  of  the  cryptogam  favours  the  decomposition  of 
the  dentine  by  exercising  upon  it  such  a  catalytic  action  as 
is  induced  by  the  introduction  of  the  yeast  plant  into  a 
saccharine  solution.  The  dentine  of  a  tooth  is  always 
more  prone  to  decay  than  its  enamel,  and  while  the  latter 
is  solid  and  free  from  defects  a  tooth  will  always  withstand 
such  injurious  influence  as  may  be  brought  to  bear  upon  it. 

As  a  rule  decay  radiates  throughout  the  dentine  from 
the  bottom  of  enamel  flaws,  and  the  presence  of  mischief 
is  often  not  revealed  by  pain  or  other  symptoms  until  the 
force  of  mastication  crushes  in  the  roof  of  enamel  that 
arches  over  a  mass  of  yielding  and  disintegrated  dentine. 
Caries  will  at  times  take  another  form  and  appear  as  a 
general  softening  of  enamel  and  dentine  around  the  necks 
of  various  teeth.  Such  a  condition  is  apt  to  occur  about 
the  middle  period  of  life  when  the  recession  of  the  gums 
and  commencing  absorption  of  the  edges  of  the  alveolar 
plates  expose  to  the  action  of  the  saliva  the  softer  and 
less  durable  cementum  that  coats  the  fangs. 

The  tendency  to  caries  shown  by  various  teeth  differs 
greatly.  Those  most  liable  to  it  are  the  four  six-year-old 
molars,  and  of  all  decayed  teeth  extracted  by  the  operator 
about  one  third  will  belong  to  this  series.  Those  least 
liable  to  this  disease  are  the  four  lower  incisors  and  two 


30  DENTAL    SURGERY    FOR 

lower  canines,  but  why  the  development  of  the  six  last  should 
be  more  complete  than  that  of  the  four  former  is  at  present 
unknown.  The  fact,  however,  remains  and  to  it  we  may 
attribute  their  far  greater  longevity. 

With  the  condition  of  the  health  generally  the  tendency 
to  decay  naturally  varies,  and  so  our  efforts  to  combat  the 
latter  should  be  both  general  and  local  in  their  nature. 
The  local  treatment  of  a  carious  tooth  should  have  a 
double  aim;  firstly,  to  relieve  the  toothache  which  is 
usually  the  exciting  cause  of  our  patient's  visit ;  secondly, 
to  preserve  the  tooth  usefully  and  to  retard  or  prevent  the 
extension  of  caries.  It  is  evident  that  the  insertion  of  gold 
fillings,  which  is  usually  the  most  successful  way  of  effect- 
ing the  last,  is  as  much  outside  the  work  of  a  medical 
practitioner  as  is  the  making  of  plates  for  artificial  teeth. 
Indeed,  the  filling  of  a  tooth  with  any  material,  be  it 
oxy chloride  of  zinc,  amalgam,  or  gold,  in  such  a  way  as  to 
make  a  perfectly  water-tight  durable  plug  that  shall  with 
certainty  prevent  any  extension  of  disease  for  a  number  of 
years,  must  come  within  the  scope  only  of  such  practi- 
tioners as  devote  their  whole  time  to  such  work.  Still 
much  remains  that  a  doctor  may  do  for  a  patient  who  is 
unable  to  visit  a  specialist.  He  may  by  treatment  of  the 
tooth,  or  its  extraction,  relieve  pain,  and  he  may  usefully 
prolong  its  existence,  though  he  can  hardly  hope  to  per- 
manently save  it,  by  carefully  filling  the  carious  cavity 
with  a  plug  of  gutta-percha  or  wool  and  mastic. 

The  course  of  dental  caries  varies  greatly  in  duration 
with  the  habits,  health,  and  age  of  the  patient,  being  most 
rapid  for   a  few  years   after   the  attainment  of  puberty. 


GENERAL    PRACTITIONERS.  31 

We  may  divide  it  into  three  stages.  Each  of  these  condi- 
tions presents  well-marked  and  unvarying  characters, 
and  familiarity  with  them  is  the  more  necessary  since 
treatment  that  serves  to  relieve  pain  from  caries  in  its 
first  stage  would,  if  adopted  in  the  second,  make  matters 
very  much  worse. 


Caries  in  its  First  Stage. 

Symptoms. — The  first  stage  of  caries  endures  until  the 
dental  pulp  or  any  portion  of  it  has  become  gangrenous. 
The  patient  complains  of  severe  intermittent  pain,  in- 
creased and  induced  by  cold  water,  hot  fluids,  the  sucking 
of  air  from  the  carious  cavity  by  the  tongue,  and  the  pre- 
sure  of  food  within  it  during  mastication.  Frequently  the 
carious  and  aching  tooth  cannot  be  exactly  indicated  by 
the  sufferer.  Pain,  as  he  says,  flies  round  the  teeth  so 
that  he  hardly  knows  which  is  in  fault.  Careful  examina- 
tion with  the  aid  of  a  mouth- mirror,  and  an  excavator 
carrying  a  small  dressing  of  absorbent  wool,  will  usually 
reveal  a  cavity  of  moderate  size  in  some  tooth  around 
which  pain  seems  to  centre.  Our  examination  shows  : — 
1.  The  tooth  is  not  discoloured.  2.  Pain  is  not  complained 
of  when  a  moderate  pressure  is  made  upon  a  sound  por- 
tion of  its  crown  with  a  strong  blunt  pointed  excavator, 
and  the  absence  of  such  pain  shows  that  the  tissues  out- 
side and  embracing  its  fangs  are  in  a  normal  condition. 
Guard,  however,  against  being  deceived  by  the  starting 
and  flinching  in  which  nervous  patients  will  indulge  at  the 
moment  of  contact  of  the  excavator  with  the  tooth.     A 


32  DENTAL    SURGERY    FOR 

good  plan  is  to  test  other  teeth  near  the  suspected  and 
carious  one  before  coming  to  the  latter.  3.  Most  acute 
and  darting  pain  is  felt  when  the  edge  of  the  excavator  is 
inserted  into  the  decayed  dentine  in  the  floor  of  the  cavity, 
or  when  the  dressing  of  wool  is  wiped  across  its  surface. 
Be  it  remembered  that  this  should  be  very  cautiously  and 
gently  conducted,  the  walls  and  floor  of  the  cavity  being 
stroked  rather  than  cut  with  the  instrument,  since  intense 
pain  may  readily  be  caused  and  the  dental  pulp,  if  not  ex- 
posed by  the  progress  of  decay,  may  be  thus  accidentally 
laid  bare.  4.  The  crucial  test,  to  ascertain  if  the  nerve  be 
still  alive  and  sensitive,  i.e.,  if  the  caries  be  still  in  its  first 
stage,  may  now  be  applied.  Inject  from  the  nozzle  of  a  small 
syringe  three  or  four  drops  of  cold  water  into  the  cavity  in 
the  tooth.  This  will  cause  severe  though  momentary  pain, 
but  before  inflicting  it  the  patient  should  be  cautioned  that 
what  is  about  to  be  done  will  probably  produce  this  re- 
sult. These  four  conditions  then ;  the  absence  of  dis- 
colouration, the  absence  of  tenderness  on  pressure  upon 
the  crown  of  the  tooth,  the  sensitiveness  of  the  decayed 
dentine,  and  the  pain  caused  by  injecting  cold  water,  go  to 
show  that  the  nerve  is  alive  and  in  a  normal,  though  per- 
haps irritated  condition,  and  that  the  first  stage  of 
caries  still  continues. * 

Tkeatment. — The  cavity  small  and  nerve  not  exposed,  or  ex- 
posed by  only  a  small  opening  through  the  wall  of  thejjuljj  cavity. 
Carefully  examine  the  bottom  of  the  cavity  to  learn  if  the 
nerve  be  exposed,  which,  if  such  be  the  case,  may  be  seen 
as  a  bleeding  highly  sensitive  spot.  If  this  be  not  evident, 
or  if  the  point  of  exposure  be  very  minute  and  the  cavity 


GENERAL    PRACTITIONERS.  33 

of  small  or  moderate  size  and  so  situated  in  the  tooth  that 
a  plug  of  wool  if  inserted  will  be  retained,  a  temporary 
filling  may  be  applied.      Before  doing  this  all  irritating 
particles  of  food   should  be  washed  from  the   cavity  by 
syringing  with  warm  water,  and  its  walls  and  floor  should 
be  dried  by  gentle  wiping  with  a  dressing  of  absorbent 
cotton-wool  upon  the  end  of  an  excavator.      The  filling 
may  consist  of  Wool  with  Carbolic  acid,  Wool  with  Tinc- 
ture of  Mastic,  or  Gutta-percha.     The  first  may  be  used 
if  the  walls  of  the  cavity  are  very  sensitive,  if  the  nerve  be 
exposed  by  a  minute  puncture,  or  if  the  tooth  be  aching 
at  Ihe  time  of  treatment.     It  may  remain  in  for  a  day  or 
two  and  then  be  replaced  by  a  similar   dressing ;    after 
which,  if  tenderness  be  lessened,  a  wool  and  mastic,  or  gutta- 
percha filling,  may  be  inserted.     In  applying  the  carbolic 
dressing  the  end  of  an  excavator  should  be  rotated  within 
a  small  piece  of  cotton-wool  held  between  the  thumb  and 
fingers.       The  wool  is  thus  rolled  into  a  compact  plug, 
the  end  of  which  may  be  dipped  into  a  phial  containing 
wool  already  saturated  with  carbolic  acid.     Thus  only  a 
small  quantity  of  the  latter  is  absorbed  by  the  dressing, 
and  indeed  a  larger  application  is  undesirable  as  it  is  apt 
to  excoriate  the  gums  and  cheek.     Care  should  be  taken 
that  the  plug  is  not  inserted  with  so  much  force  as  to 
cause  pain  by  pressure  upon  a  nerve   possibly   exposed ; 
and  sometimes  when  the  application  of  carbolic  acid  fails 
to   soothe   an  aching  dental  pulp   relief  may  be   readily 
obtained  by  the  substitution  for  it  of  thymol  or  eucalyptin. 
The  wool  and  mastic  plug   may  be   inserted  when   the 
cavity  has  only  slight  tenderness.     In  applying  it,  the  end 

D 


34  DENTAL    SURGERY    FOR 

of  an  excavator  should  be  armed  as  before  with  a  little 
cotton-wool,  which  may  be  dipped  into  a  strong  solution 
of  gum  mastic  in  alcohol,  after  which  a  little  dry  wool 
should  be  wrapped  around  the  plug.  This  may  be  intro- 
duced into  the  cavity,  which  has  previously  been  washed 
out  and  dried,  and  maybe  allowed  to  remain  for  a  few  days, 
after  which  it  is  apt  to  acquire  an  offensive  odour  and  should 
be  changed.  The  gutta-percha  filling  may  be  used  under  such 
conditions  of  the  tooth  and  cavity  as  make  a  wool  and  mastic 
plug  possible,  and  it  is  more  durable  and  less  absorbent 
of  the  fluids  of  the  mouth  than  the  last.  Its  durability 
will  be  greatly  increased  if,  after  washing  and  drying  the 
cavity  as  before,  a  sharp  excavator  be  carried  round  the 
walls  of  the  cavity,  removing  the  softened  dentine  until  the 
underlying  hard  tooth  structure  is  reached.  In  so  doing- 
care  must  be  taken  to  cause  but  little  pain,  and  not  to 
expose  the  dental  pulp.  To  avoid  this  last,  operate  only 
on  the  edges  of  the  cavity,  leaving  untouched  on  its  floor 
the  carious  tissue.  The  gutta-percha,  having  been  warmed 
over  a  candle  flame,  should  be  inserted  while  soft,  and 
while  only  so  hot  that  it  may  be  applied  to  the  back  of  the 
operator's  hand  without  causing  any  pain.  If  the  cavity  be 
dry  while  it  is  being  filled,  and  if  such  a  stopping  be  in  con- 
tact all  round  with  hard  walls,  it  may  endure  for  some  years  ; 
but  be  it  remembered  that  the  durability  of  any  stopping  is 
proportionate  to  its  faculty  for  excluding  moisture.  In  this 
connection  reference  to  gold,  amalgam,  and  oxychloride 
fillings  is  purposely  omitted,  such  materials  having  no 
value  save  in  the  hands  of  those  trained  to  their  use. 
The  employment  of  temporary  plugs  has,  however,  been 


GENERAL    PRACTITIONERS.  35 

treated  of  at  some  length,  as  such  will  often  do  good  service 
in  allaying  toothache,  and  preventing  for  a  considerable 
time  its  return,  by  their  exclusion  of  food,  cold  air,  and 
hot  and  cold  fluids  from  the  sensitive  surface. 

The  cavity  large  and  nerve  exposed. — Under  these  circum- 
stances it  may  be  impracticable  to  retain  a  temporary 
filling  in  the  tooth,  either  on  account  of  its  extreme  sen- 
sitiveness and  constant  aching,  or  from  the  absence  of 
such  adjacent  teeth,  or  overhanging  walls  to  the  cavity,  as 
would  prevent  the  plug  from  coming  out  during  mastica- 
tion. Usually  under  these  conditions  extraction  is  the  best 
course  to  adopt,  but  the  health  of  the  patient  or  other 
causes  may  prohibit  this.  The  employment  of  arsenic  is 
then  indicated  and  should  be  thus  applied.  Equal  parts 
of  yellow  soap  and  arsenious  acid  are  to  be  well  worked 
into  a  bolus,  of  which  a  pellet,  as  large  as  the  head  of  a  good 
sized  pin,  should  be  carried  on  an  excavator  into  the 
bottom  of  the  washed  and  dried  cavity,  as  near  as  jjo-ssible 
to  the  point  of  exposure  of  the  pulp.  The  pellet  may  be 
held  in  situ  by  a  plug  of  wool,  which  should  be  removed 
after  24  hours  and  replaced  with  a  wool  and  mastic  filling. 
One  application  of  arsenic  generally  suffices  to  devitalize 
a  dental  pulp,  but  sometimes  a  second  and  smaller  piece 
may  be  introduced  into  the  tooth  after  two  or  three  days, 
if  it  be  found  still  sensitive  to  cold  water  from  the  syringe. 
The  pain  caused  by  the  action  of  arsenic  on  a  pulp  is 
generally  severe  for  three  hours  and  commences  within 
half  an  hour  of  its  application.  After  six  hours  the  pain 
has  generally  quite  departed,  and  the  condition  of  the  tooth 
so  changed  that  the  patient  no  longer  dreads  to  inhale  a 

d2 


36  DENTAL    SURGERY    FOR 

deep  breath  of  cold  air  or  to  brush  the  teeth  with  cold 
water.  Thus,  at  the  expense  of  a  temporary  increase  in 
such  toothache  as  he  may  have  already  long  suffered,  may 
be  gained  complete  relief,  and  the  tooth,  though  its  exist- 
ence may  not  be  prolonged,  will  no  longer  remain  a  con- 
stant source  of  pain.  In  applying  arsenic  guard  against 
allowing  the  soft  pellet  to  be  squeezed  out  of  the  cavity, 
while  the  wool  plug  is  being  introduced,  so  that  it  is 
brought  into  contact  with  the  surrounding  gum.  Thus 
much  painful  ulceration  may  be  caused,  and  no  beneficial 
action  upon  the  aching  dental  pulp  result.  Guard  also 
against  using  a  pellet  larger  than  the  head  of  a  good  sized 
pin  ;  and  also  avoid  its  use  altogether  if  decay  has  so  far 
advanced  that  both  walls,  or  the  floor  of  the  pulp  cavity, 
are  perforated  so  that  the  caustic  should  exert  its  destruc- 
tive influence  upon  the  socket  on  the  opposite  side  of  the 
tooth. 

Caries  in  its  Second  Stage. 

The  second  stage  of  dental  caries  has  been  reached  when 
the  dental  pulp,  or  any  portion  of  it,  has  become  gan- 
grenous, i.e.,  dead  and  decomposing.  Such  a  condition 
always  results  from,  decay  when  it  is  allowed  to  go  on  un- 
checked by  natural  or  artificial  means.  A  natural  limita- 
tion of  caries  sometimes  occurs  when  the  disease  in  its 
progress  reaches  a  substratum  of  solid,  well- developed, 
non- absorbent  dentine.  Then  we  find  the  floor  of  the 
cavity  composed  of  hard  dark  ivory,  which  shows  no 
tendency  to   softening.      The  artificial  means   employed 


GENERAL    PRACTITIONERS.  37 

to  permanently  arrest  decay  consist  in  excavating  and 
filling  the  tooth  with  some  imperishable  material,  or  in 
cutting  out  the  decayed  tissue  and  carefully  polishing  the 
resulting  surface. 

As  a  consequence  then  of  the  advancing  caries  the  pulp 
becomes  irritated,  aches,  and  at  last  takes  on  a  process  of 
destructive  inflammation,  by  which  after  several  hours  of 
severe  pahi  its  vitality  is  destroyed.     Or  this  last  condition 
may  be  reached  more  gradually  and  without  any  attack  of 
severe  pain.     Here  it  may  be  noted  that  the  vitality  of  a 
dental  pulp  may  depart  without  any  pre- existent  decay  and 
as   a  result   of  a  generally   depressed  condition    of   the 
health ;    or  again  it  may  be  destroyed  by  a  violent  blow 
upon  the  tooth  ;    also  by  the  action  of  arsenious  acid  em- 
ployed as  before  mentioned.     The  pulp  having  lost  vitality 
will  in  a  few  weeks  become  putrescent,  evolving  the  usual 
gaseous  products  of  decomposition.     The  pulp  cavity  and 
the  canals  down  each  fang  are  now  charged  with  a  dark, 
viscid,  fetid  substance,  from  which  gas  is  constantly  es- 
caping by  any  opening  that  may  exist  through  the  wall  of 
the  pulp  cavity.    This  opening  may  be  found  at  the  bottom 
of  the  original  cavity  of  decay,  the  result  of  the  softening 
and  destructive  action  of  disease  upon  the  dentine,  or  it 
may  have  been  made  artificially  by  the  excavator  of  the 
operator.     Such  is  the  usual  course  of  events  : — the  putre- 
faction of  a   dental  pulp  follows  its  death,  unless,  when 
arsenic  has  been  used  to  induce  this,  a  careful  antiseptic 
treatment  has  been  employed. 

To  achieve  this,  to  destroy  a  pulp  and  to  protect  it  subse- 
quently from  septic  change,  a  minute  attention  to  these 


38 


DENTAL    SURGERY    FOR 


Fig.  18. 


details  is  needed.  The  central  cavity  and  the  fang  canals 
should  be  cleared  three  days  after  the  application  of  arsenic 
of  all  devitalized  organic  filaments  by  inserting  and  with- 
drawing minutely  barbed  and  antiseptic  ally  treated  steel 
instruments. 

The  fang  canals  and  central  cavity  should 
then  be  dried  with  absorbent  wool,  and  should 
be  filled  with  filaments  of  wool  saturated  with 
carbolic  acid.  These  should  be  tightly  coin- 
pressed  within  the  tooth  and  allowed  to  re- 
main, while  over  them  the  permanent  metal 
stopping  is  inserted.  Thus  the  tooth  may  be 
made  to  last  for  many  years,  protected  by  the 
stopping  from  the  advance  of  caries,  and  by 
the  carbolised  wool  within  it  from  the  genera- 
tion of  products'  of  decomposition  ;  its  vitality 
being  sustained  through  the  membrane  cover- 
ing the  cementum  of  its  fangs. 

In  the  absence  of  such  antiseptic  measures, 
the  death  of  the  pulp,  whether  it  come 
from  the  advance  of  caries,  from  depressed 
state  of  general  health,  from  traumatic  cause, 
or  from  arsenical  action,  induces  putre- 
factive change  within  the  pulp  cavity.  So 
long  as  the  evolved  gas  can  escape  freely  into 
the  mouth  no  special  symptoms,  beyond  a 
disagreeable  odour  of  the  breath,  result.  If, 
however,  there  be  no  such  opening  through 
the  wall  of  the  pulp  cavity,  or  if  one  that  has 
tor  for  removing  existed,  or  has  been  made,  be  plugged  up  by 
tal  nerve.  a  particle  of  food,  or  by  a  filling  of  any  kind 


GENERAL    PRACTITIONERS.  39 

inserted  by  the  operator,  we  find  at  once,  or  within  a 
few  hours,  a  special  and  characteristic  set  of  symptoms 
induced.  The  septic  gas  now  collects  within  the  pulp 
cavity,  where  it  is  pent  up  unable  readily  to  escape,  and  it 
may  cause  very  severe  toothache  within  half  an  hour  of  the 
plugging  up  of  the  hole  if  there  be  a  small  portion  of  the 
pulp  still  alive  in  one  of  the  fangs. 

To  the  pressure  of  such  elastic  vapor  thus  suddenly  ap- 
plied to  a  dental  nerve  of  which  the  upper  part  was  gan- 
grenous while  the  lower  half  was  alive  and  sensitive,  and  to 
no  other  cause,  can  I  attribute  the  severe  pain  which  I  had 
an  opportunity  of  observing  within  twenty  minutes  of  the 
closure  of  an  opening  at  the  bottom  of  a  carious  cavity  and 
leading  into  the  pulp  chamber  from  which  a  discharge  was 
escaping  from  a  semi-devitalized  pulp.  My  opinion  as  to 
the  mode  in  which  pain  was  induced,  and  which  always 
.occurred  within  a  short  time  of  the  aperture  being  blocked 
by  particles  of  food,  was  confirmed  when  the  tooth  was 
subsequently  removed,  when  on  splitting  it  open  the  deeper 
lying  parts  of  its  nerve  tissue  were  found  to  be  perfectly 
healthy,  those  nearer  the  surface  being  gangrenous. 

If,  however,  the  pulp  be  entirely  gangrenous  throughout, 
the  pressure  of  the  pent  up  gas  serves  to  force  out  some  of 
the  softened  and  decomposed  nerve  tissue  through  the 
openings  at  the  fang  extremities  into  the  socket  of  the 
tooth.  The  extrusion  of  such  septic  particles  into  proxi- 
mity with  the  healthy  membrane  lining  the  socket  serves  in 
most  cases  to  induce  more  or  less  severe  periodontitis,  the 
cause  of  which,  when  it  is  localized  around  one  tooth,  is  al- 
most invariably  such  as  has  been  indicated,  and  it  is  a 


40  DENTAL    SURGERY    FOR 

tooth  producing  this  condition  which  is  popularly  said  to 
have  "  caught  a  cold." 

Periodontitis,  then  is  in  almost  all  cases  preceded  by 
the  death  and  putrefaction  of  the  whole  of  the  pulp 
and  the  extrusion  of  putrescent  particles  through  the 
openings  at  the  ends  of  the  fangs.  My  own  experience 
induces  me  quite  to  dissent  from  the  views  of  those 
who  hold  that  periodontitis  may  result  from  extension 
of  inflammation  from  an  inflamed  pulp  within  a  tooth  to 
the  healthy  tissue  outside  its  fangs,  and,  in  support  of  my 
view,  I  may  say  that  I  have  never  yet  met  with  periodon- 
titis, attended  with  suppuration,  around  the  fangs  of  teeth 
containing  vital  nerves.  On  opening  into  the  pulp  cavi- 
ties of  such  teeth  as  were  causing  periodontitis,  their  pulps 
have  always  been  found  to  be  in  a  decomposed  state,  and  it 
is  not  evident  how  inflammatory  action  can  extend,  as  has 
been  asserted,  from  a  tissue  which  is  itself  already  dead. 

We  find  further  evidence  in  support  of  the  cause  here 
assigned  for  the  production  of  periodontitis,  localised 
around  one  tooth,  in  the  fact  that  the  condition  may  be 
almost  invariably  relieved  in  a  few  hours  by  drilling 
through  the  walls  of  the  pulp  chamber,  and  so  allowing  the 
gas  to  escape  into  the  mouth  rather  than  through  the  fang 
ends.  If  the  opening  so  made  be  accidentally  or  inten- 
tionally closed  in  the  course  of  a  day  or  two,  the  gas  which 
collects  within  the  pulp  cavity  will  again  force  its  way  into 
the  socket  through  the  openings  of  the  fangs,  and  thus  acute 
periodontitis  may  be  once  more  set  up.  It  may  be  noted 
that  the  rheumatic  diathesis,  mercurial  treatment,  or  a 
traumatic  cause,   may   produce    sub- acute  inflammatory 


GENERAL    PRACTITIONERS.  41 

change  within  the  maxillary  socket ;  but  this  may  he  dis- 
tinguished from  periodontitis  arising  from  putrefactive 
change  within  a  pulp  cavity.  The  latter  is  at  first  localized 
beneath  one  tooth,  which  is  tender  to  pressure,  often  much 
decayed,  and  with  pus  escaping  around  its  neck  if  the  in- 
flammation in  the  neighbourhood  of  its  fangs  have  pro- 
ceeded to  the  production  of  an  alveolar  abscess. 

Periodontitis  thus  caused  by  a  process  of  putrescent 
inoculation  may  be  acute  or  chronic. 

Symptoms  of  Acute  Periodontitis. — 1.  Dull,  aching,  contin- 
uous pain  around  a  tooth  which  is  usually  much  decayed.  It 
must  be  noted,  as  has  already  been  observed,  that  the  pulp 
may  die  and  decompose  within  a  tooth  that  is  in  no  way 
affected  by  caries ;  so  the  presence  of  a  cavity  is  not  in- 
variable, and  acute  periodontitis  may  occur  around  the 
teeth  of  old  persons,  or  of  those  in  feeble  health,  or  as  a 
sequence  to  some  injury  that  has  devitalized  a  dental  pulp. 
2.  The  tooth  is  slightly  raised  from  its  socket  and  so 
stands  above  the  level  of  its  neighbours  and  to  the  patient 
feels  "  longer  "  than  others.  This  comes  from  the  swelling 
of  the  tissues  inside  the  socket,  whereby  the  conical  fangs 
are  slightly  lifted  out.  From  the  same  cause  the  tooth  is 
rather  loosened  and  may  be  rocked  readily  from  side  to 
side.  3.  It  is  very  tender  on  pressure  and  tapping,  and 
this  results  from  the  communication  of  the  force  through 
the  tooth  to  the  highly  sensitive  and  inflamed  tissues 
around  its  fangs.  In  applying  this  test  it  is  well  to  tap 
other  teeth  before  the  suspected  one  so  that  the  element  of 
nervousness  may  be  excluded.  4.  Our  crucial  test  is  to 
inject  cold  water  with  a  syringe  into  the  carious  cavity, 


42  DENTAL    SURGERY  -FOR 

which  of  course,  as  the  nerve  is  quite  dead,  causes  no  pain. 
On  cutting  the  decayed  dentine  very  lightly  with  a  sharp 
excavator  there  is  also  no  pain  produced,  since  there  is  no 
longer  sensation  in  the  tooth.  If  the  instrument  be  used 
at  all  forcibly  the  patient  will  complain,  but  this  comes 
irom  pressure  of  the  tooth  into  its  inflamed  socket,  and 
cannot  be  mistaken  for  the  acute  pain  caused  by  cutting 
the  dentine  of  a  tooth  affected  by  caries  in  its  first  stage. 
5.  Around  the  fangs  and  within  the  socket  a  collection  of 
pus  soon  forms,  which  discharges  around  the  neck  of  the 
tooth,  and  with  the  formation  of  this  Alveolar  Abscess,  as 
it  is   termed,  relief  from  pain  is  generally  experienced. 

The  pain  and  inflammation  may  now  subside,  and  the 
tooth  may  become  fairly  firm  again,  but  while  it  remains  in 
the  mouth  it  is  likely  to  cause  again  similar  trouble,  or  to 
act  as  a  source  of  chronic  periodontitis. 

Treatment  of  Acute  Periodontitis. — As  a  rule  it  is  best  to 
extract  the  tooth  causing  the  mischief ;  but  relief  may 
usually  be  given  in  an  hour  or  two  by  opening  into  the 
pulp  chamber  through  its  walls  at  any  part  with  an  ex- 
cavator or  sharp  drill.  By  so  doing  the  imprisoned  gas, 
generated  of  the  putrefaction  that  is  going  on  within  the 
tooth,  is  permitted  to  escape  freely  into  the  mouth,  and  so 
is  no  longer  compelled  to  leak  from  the  fang  ends.  The 
opening  should  be  free,  and  kept  patent  by  a  filling' of  dry 
cotton- wool,  loosely  inserted  and  changed  daily.  This  treat- 
ment may  be  applied  to  such  teeth  as  it  may  not  be  desir- 
able to  extract,  and  relief  from  pain  may  be  almost  certainly 
promised.  The  decayed  temporary  molars  of  children  may 
be  so  treated  (vide  ante  Chapter  I.),  also  among  adults  we 


GENERAL    PRACTITIONERS.  43 

may  thus  relieve  inflammation  around  a  tooth  which  may 
be  valuable  for  appearance  or  mastication.     Extraction,  or 
opening  into  the  pulp  cavity,  afford  the  only  means  of  re- 
lieving acute  periodontitis,  and  a  slight  consideration  of 
the  cause  leading  up  to  this  condition  will  serve  to  con- 
vince of  the  absolute  inutility  of  applying  escharotics  or 
counter-irritants  to  the  gum  overlying  the  affected  part.    A 
popular  impression  is  apt  to  prevail  as  to  the  undesira- 
bility  of  extracting  a  tooth  around  the  fang  of  which  acute 
inflammatory  action,  or   an  alveolar  abscess,  is  existing. 
This  it  may  be  said  is  quite  erroneous.      With  the  removal 
of  the  tooth  that  is  the  cause  of  the  periodontitis,  whether 
the  latter    be    attended  with   the   formation    of    matter 
or  not,  the  pain  and  swelling  in  and  around  the  alveolar 
structures  will  soon  subside,  and,  if  extraction  be  deemed 
desirable,  the   operation   should  be   effected  without  any 
delay.      Not  infrequently  a  good  deal  of  dull  aching  pain 
with  a  sense  of  tension  and  throbbing  within  the  socket  will 
follow  the  removal  of  the  tooth.     This  may  endure  for  two 
or  three  days  unless  relief  be  given  by  occasionally  raising 
from  the  site  of  extraction  with  the  point  of  an  excavator 
the  firm  blood-clot  beneath  which  sanguineo-purulent  fluid 
is  apt  to  collect  and  be  pent  up  within  the  inflamed  socket. 
This  is  a  point  of  some  importance  and  the  patient,  if  un- 
able to  obtain  medical  assistance  daily,  should  be  instructed 
to  perform  the  operation  for  himself,  using  for  the  purpose 
the  point  of  a  pair  of  scissors  or  the  end  of  a  sharpened 
quill. 

Symptoms  of  Chronic  Periodontitis.  —  The  inflammatory 
action  set  up  around  the  fangs  may  take  a  chronic  form, 


44  DENTAL    SURGERY    FOR 

though  the  cause  is  the  same  whether  the  periodontitis 
be  acute  or  chronic,  and  relief  may  be  given  by  similar 
treatment  in  both  cases.  The  gaseous  products  of  decom- 
position from  the  interior  of  the  tooth  leaking  through 
the  fang  ends,  with  the  purulent  secretion  that  forms 
around  it  within  its  socket,  escape  through  a  sinus  which 
usually  opens  through  the  outer  alveolar  plate  and  the 
gum  covering  it.  The  orifice  of  such  sinus  is  marked  by 
a  small  papilla,  or  gum-boil  as  it  is  termed,  from  which 
pus  may  be  often  found  escaping  in  small  quantities.  The 
gum-boil  may  at  times  be  found  on  the  palatine  mucous 
membrane  over  the  inner  fang  of  an  upper  molar,  but 
as  a  rule  it  is  placed  on  the  outer  surface  of  the  gum. 
This  condition  may  endure  for  several  years,  the  gum- 
boil alternately  coming  and  going,  and  the  tooth  slightly 
loosened  in  its  socket  and  occasionally  tender  on  pressure. 
An  alteration  in  the  colour  of  a  tooth  containing  a  decom- 
posed pulp  is  generally  evident  in  the  course  of  a  few 
weeks  from  the  time  at  which  the  latter  became  devitalized. 
The  coffee- coloured  fluid  within  the  pulp  chamber  fills  the 
dentinal  tubules,  stains  the  dentine,  and  its  dark  tint  is 
apparent  through  the  semi-translucent  enamel.  If  then 
any  tooth  in  the  neighbourhood  of  which  there  is  a  gum- 
boil, and  which  is  a  little  loose,  and  occasionally  rather  ten- 
der, shows  on  examination  by  daylight  a  darker  tint  than  its 
neighbours  we  may  safely  conclude  that  its  contained  pulp 
is  decomposed,  and  that  a  condition  of  chronic  periodontitis 
is  established  around  its  fangs.  In  such  a  condition  we 
often  find  a  tooth  containing  a  large  stopping  under  which 
the  pulp  has  died  and  decomposed,  or  in  which  the  pulp 


GENERAL    PRACTITIONERS.  45 

at  the  time  of  stopping  was  devitalized  by  the  operator 
with  the  aid  of  arsenic.  It  should  be  noted,  however,  that 
if  such  antiseptic  precautions  as  have  already  been  men- 
tioned be  taken  after  the  use  of  the  latter  there  is  but 
little  fear  that  putrefactive  changes  within  the  tooth,  and 
chronic  periodontitis  around  its  fangs,  will  be  the  sequel  to 
its  stopping.  Such  a  mishap  may  generally  be  attributed  to 
the  neglect  of  such  precautions,  or  to  the  imperfect  manner 
in  which  they  have  been  carried  out.  It  is  not  unusual  to 
find  a  tooth,  which  has  for  some  years  caused  in  the  manner 
described  a  slight  irritation  within  its  socket  and  a  gum- 
boil over  its  fang-ends,  becoming  eventually  quiet  and  ceas- 
ing to  trouble  by  the  generation  and  extrusion  of  putrefac- 
tive products  from  its  interior.  Frequently,  however,  such 
teeth  become  gradually  loosened  and  are  shed,  or  by  their 
becoming  a  source  of  pain  their  extraction  is  necessitated. 
Then  their  fangs  are  found  to  be  rough  and  partly  eroded 
towards  then-  extremities,  around  which  also  are  adherent 
shreds  of  fibrous  exudation. 

Treatment  of  Chronic  Periodontitis. — Chronic  periodontitis, 
whether  it  be  caused  by  a  carious  tooth  ;  by  a  tooth  sound 
as  regards  decay ;  or  by  a  tooth  in  which  a  stopping  has 
been  inserted,  may  be  relieved  by  drilling  or  excavating  an 
opening  through  the  walls  of  the  pulp  chamber,  or  through 
the  stopping  as  the  case  .may  be.  Such  a  hole  may  be 
minute,  and  may  be  drilled  through  the  outer  side  of  its 
fang  on  a  level  with  the  edge  of  the  gum,  an  operation  to 
which  the  name  of  rhizodontrcphy  has  been  given.  Thus  a 
vent  is  afforded  to  the  imprisoned  gas,  the  irritation  within 
the  socket  is  usually  allayed,  and  the  gum -boil  disappears 


46  DENTAL    SURGERY    FOR 

and  is  absent  so  long  as  the  opening  into  the  pulp  cham- 
ber  remains  patent.      By  a  careful  introduction  of  car- 
bolic acid  or  Condy's  fluid  into  the  fangs,  if  access  can  be 
obtained  thereto,  the  putrefactive  change  may  be  partially 
arrested ;  but  such  an  operation  can  at  the  best  be  only  im- 
perfectly performed,  and  the  dentinal  tubules,  charged  as 
they  are  with  fetid  organic  matter,  remain  inaccessible  to 
the  agents  and  instruments  of  the  operator.      If  the  pulp 
has  but  recently   died   and   decomposed  these   measures 
should  be  adopted  and  have  great  value,  but  if  the  stain- 
ing of  the  tooth  shows  that  the  septic  change  is  of  long 
standing  they  cannot  be  expected  to  prevent  further  putre- 
factive change  within  the  tooth.  Care  should  be  taken  when 
introducing  Condy's  fluid  on  the  dressing  of  wool  into  a 
fetid  fang  lest  any  decomposed  organic  matter  be  driven  be- 
fore the  piston  through  the  opening  at  the  fang  end.    Such 
a  mishap  has  frequently  resulted  in  the  treatment,  which 
was  designed  to  relieve  chronic  periodontitis,  becoming  in  it- 
self a  cause  of  acute  inflammatory  action  within  the  socket. 


Caries  in  its  Third  Stage. 

If  decay  advance  unchecked  the  crown  of  the  tooth 
disappears,  leaving  sharp  spicule  of  enamel  that  are  apt,  un- 
less filed  down,  to  excoriate  the  cheek  or  tongue.  With  the 
disappearance  of  the  crown  decay  may  be  said  to  have 
reached  its  third  stage,  and  nought  now  remains  of  the 
tooth  save  the  fangs,  the  dentine  of  which  has  become  ca- 
rious and  softened,  and  which  contain  the  debris  of  dead 
and  decomposed  nerve  tissue.      Such  stumps  may  remain 


GENERAL    PRACTITIONERS.  47 

for  years  without  causing  any  trouble,  but  frequently  they 
set  up  a  condition  of  chronic  inflammation,  as  the  result  of 
which  they  may  become  rough  and  eroded  and  more  or 
less  enlarged  or  exostosed,  as  it  is  termed.    Moreover,  by  an 
exudation  around  them  of  inflammatory  lymph,  they  may 
be  glued  into  then  sockets  so  tightly  that  their  extraction 
becomes  at  times  no  easy  task.     The  difficulties  met  with 
in  the  removal  of  such  stumps  arise  from  three  causes  : 
1.  the  glueing  of  the  fang  into  its  socket  which  prevents 
the  ready  introduction  of  the  blades  of  the  forceps  ;  2.  the 
hollowed  condition  of  the  interior  of  the  fang  which  induces 
its  walls  to  collapse  as  soon  as  the  instrument  is  forcibly 
closed  upon  it ;   3.  the  exostosed  condition  of  its  surface, 
which  is  often  caused  by  chronic  periodontitis,  and  by  which 
it  is  firmly  rivetted,  as  it  were,  into  the  maxilla.     Pain, 
when  it  is  caused  by  decaying  stumps,  is  of  a  neuralgic 
nature,  not  located  around  its  exciting  cause,  but  intermit- 
tent and  flying  over  the  side  of  the  face  and  head,  and  it  is 
increased  by  hunger,  fatigue,  or  other  depressing  cause. 
As  to  the  propriety  of  removing  such  fangs  there  can  be  no 
question.     With  their  removal  the  neuralgic  trouble  will 
vanish,  and  it  may  be  confidently  stated  that  facial  neural- 
gia has   almost  invariably   a  dental  cause.      Stumps,  if 
quiet,  may  be  disregarded,  since  they  may  be  of  a  certain 
use  in  masticating  food  ;  but,  if  it  be  thought  desirable  that 
artificial  teeth  should  be  worn,  it  is  generally  well  to  ex- 
tract all  such  stumps  as  are  causing  any  local  or  nervous 
irritation  before  taking  the  models  to  which  the  frames  are 
to  be  constructed. 

It  should  be  noted  that  chronic  inflammatory  action  or 


48  DENTAL    SURGERY    FOR 

irritation,  when  produced  by  any  of  the  six  lower  molars  or 
their  fangs,  is  apt  to  prove  the  cause  of  the  two  following 
well  marked  conditions,  which,  though  they  may  be  caused 
by  other  teeth,  are  not  often  associated  with  disease  of  any 
but  the  lower  molars. 

1.  Closure  of  the  jaws. — This  rarely  results  from  irritation 
save  that  which  is  caused  by  a  second  or  third  lower  molar, 
and  more  often  comes  from  the  latter  than  the  former  tooth. 
Inflammatory  exudation,  slowly  organized  into  fibrous 
bands,  may  have  slowly  formed  around  the  temporo-maxil- 
lary  articulation  on  the  affected  side,  and  by  its  gradual 
contraction  may  have  so  reduced  the  opening  into  the 
mouth  between  the  incisor  teeth  that  the  introduction  of 
solid  food  may  have  become  almost  impossible.  Under  these 
circumstances  the  patient  should  be  well  anaesthetised  and 
the  mouth  forcibly  opened  with  the  aid  of  a  powerful  screw 
gag  (vide  fig.  30)  placed  between  the  bicuspid  teeth.  Pres- 
sure should  bear  upon  these  rather  than  upon  the  incisors, 
since  the  latter  may  be  broken  or  dislocated  by  the  required 
force.  The  ligamentous  adhesions  around  the  articulation 
being  thus  stretched,  the  dental  cause  of  the  mischief  may 
be  searched  for,  and  should  be  entirely  removed.  For  the 
after  treatment  of  such  cases  a  daily  separation  of  the  teeth 
should  be  gently  and  gradually  effected  with  the  aid  of  the 
screw  gag,  and  will  serve  to  restore  in  a  week  or  two  the 
original  mobility  of  the  jaw. 

2.  Fistulous  opening  through  the  cheek. — This  rarely  pro- 
ceeds from  any  but  the  lower  molars,  and  of  these  the 
first  molar  is  more  apt  than  the  second  or  third  to  prove 
the  cause.     It  may  be  apprehended  when  the  cheek  over- 


GENERAL    PRACTITIONERS.  4g 

lying  the  seat  of  periodontitis,  whether  this  be  acute  or 
chronic,  is  found  to  become  glazed,  reddened,  and  adherent 
to  subjacent  structures.  No  time  should  then  be  lost  in 
extracting  the  tooth  or  stumps  that  appear  to  be  causing 
mischief,  and  thus  by  timely  action  the  disfigurement  may 
be  averted.  The  fistulous  opening  when  once  established 
may  remain  for  years  a  channel  through  which  puru- 
lent fluid,  secreted  around  the  diseased  fangs,  occasionally 
escapes.  After  a  time  the  discharge  may  cease  by  natural 
causes ;  but  the  extraction  of  the  stump,  which  being 
usually  glued  into  its  socket  is  sometimes  difficult  of  re- 
moval, will  at  once  cure  the  condition,  if  it  be  not  so  far 
advanced  that  necrosis  of  a  portion  of  maxilla  has  been 
induced.  If  this  last  exist  the  healing  must  of  course  be 
delayed  until  the  dead  structure  has  been  thrown  off  or 
removed,  but  always  an  unsightly  pucker  in  the  face  will 
mark  the  site  of  the  old  fistulous  opening. 


E 


50  DENTAL    SURGERY    FOR 


Chapter  VI. 

TOOTHACHE. 

Odontalgia,  Periodontitis,  Gas  Pressure  on  the   Nerve, 

Neuralgia. 

Pain  in  or  around  a  tooth  is,  as  a  rule,  one  of  the  at- 
tendants upon  its  decay  at  some  stage  of  the  disease,  and 
usually  takes  one  of  the  following  forms. 

I.  Odontalgia,  or  the  pain  that  accompanies  the  first  stage 
of  decay  (see  Chap.  V).  This  varies  in  severity,  is  inter- 
mittent, and  at  times  comes  on  in  sharp  paroxysms.  It 
is  located  usually  in  the  aching  tooth,  but,  if  a  lower 
wisdom  tooth  be  affected,  it  may  fly  up  into  the  neigh- 
bourhood of  the  ear.  It  is  increased  and  induced  by  hot 
and  cold  fluids,  cold  air,  pungent  or  sweet  food,  and  pres- 
sure of  particles  into  the  carious  cavity  during  mastica- 
tion ;  while,  as  its  cause,  is  always  to  be  found  some  tooth 
of  which  the  crown  is  more  or  less  damaged  by  decay  or 
mechanical  violence,  and  of  which  the  dental  pulp  is  in  a 
vital,  highly  sensitive,  and  irritated  condition. 

The  treatment  of  odontalgia  must  vary  with  the  local 
condition  producing  it.  If  decay  be  not  far  advanced,  and 
the  nerve  not  exposed,  or  exposed  by  only  a  small  aper- 
ture, the  cavity  should  be  syringed  out  with  warm  water, 
and  should  be  x^lugged  with  a  dressing  of  wool  and  carbolic 
acid  (see  Chap.  Y).      Thus  the  irritated  pulp  is  soothed, 


GENERAL    PRACTITIONERS.  51 

and  protected  by  a  non-conductor  of  heat  from  thermic  and 
other  influences.  The  wool  may  be  changed  daily,  or  may 
be  replaced  in  a  few  days  by  a  filling  of  gutta-percha. 
Should  the  cavity  be  large  and  the  pulp  freely  exposed  it 
will  probably  be  necessary  to  destroy  the  latter  with  the 
aid  of  arsenic  (see  Chap.  V),  or  to  extract  the  tooth. 

II.  That  which  attends  Acute  Periodontitis. — Such  pain  is 
constant,  as  distinguished  from  the  intermittent  pain  of 
odontalgia.  It  is  at  first  dull,  but  becomes  more  severe  as 
the  inflammation  increases,  and  endures  often  until  a 
discharge  of  pus  takes  place,  which  wells  up  around  the 
neck  of  the  tooth  from  the  alveolar  abscess  that  may  have 
formed  within  the  socket  around  its  fangs.  With  the 
formation  of  matter  a  sensation  of  throbbing  is  experienced 
within  the  maxilla,  and  considerable  swelling  of  the  soft 
parts  around  the  seat  of  mischief  is  then  noticeable.  The 
tooth  becomes  very  tender  to  pressure  or  gentle  tapping,  is 
raised  from  its  socket,  and  so  loosened  that  its  crown  may 
at  times  be  readily  moved  laterally  to  and  fro,  but  it  is 
not  sensitive  to  hot  or  cold  fluids.  Its  pulp  cavity  and  fang 
canals  contain  always  dead  and  decomposed  nerve  tissue, 
from  which  septic  particles  have  been  extruded  into  the 
alveolar  sockets  through  the  orifices  at  the  ends  of  the  fangs 
by  expansion  of  gaseous  products  of  putrefaction  pent  up 
within  the  pulp  cavity  (see  Chap.  V).  A  tooth  thus  cir- 
cumstanced is  usually  found  to  be  much  decayed,  but,  as 
before  mentioned,  periodontitis  may  be  induced  by  the 
action  of  one  in  which  the  pulp  has  lost  its  vitality 
from  causes  other  than  caries,  as  from  a  blow,  or  from 
general  ill-health.      To  relieve   the  pain  of  periodontitis 

e2 


52  DENTAL    SURGERY    FOR 

the  pulp  cavity  should  be  opened  with  a  drill  or  an  exca- 
vator, so  that  the  pent  up  gas  may  escape,  or,  if  the 
mischief  be  far  advanced,  the  tooth  should  be  extracted. 
The  latter  operation,  as  before  said,  may  be  performed  at 
any  stage  of  the  disease  ;  indeed,  the  more  severe  the  in- 
flammatory action  may  be,  the  more  needful  it  becomes  to 
extract  the  tooth. 

III.  That  caused  by  gas  pressure  upon  a  sensitive  portion  of 
a  dental  pulp. — Such  pain  is  most  intense,  constant,  of 
several  hours  in  duration,  and  located  strictly  within  the 
affected  tooth.      This  will  be  found  to  contain   semi-gan- 
grenous nerve  tissue  ;    that  portion  of  the  latter  situated 
within  the  fang  canals  being  still  vital  and  sensitive,  while 
that  occupying  the  pulp  chamber  has  lost  vitality,  is  gan- 
grenous  and  evolving  gaseous  products   of  putrefaction. 
These,  pent  up  within  the  sealed  pulp  chamber,  unable  t'j 
discharge  themselves  into  the  mouth,  produce  by  their  in- 
creasing pressure  on  the  nerve  filaments   still   retaining 
sensibility  the  intense  pain  that  accompanies  this  condition, 
which  may  endure  until  the  vitality  of  the  whole  of  the 
nerve  has  been   destroyed.      The   tooth   thus   affected  is 
sensitive  to  neither  heat  nor  cold,  since  its  nerve  is  par- 
tially dead ;  nor  is  it  tender  on  tapping,  since  as  yet  no 
periodontitis  exists  within  its  socket.      Belief  may  be  in- 
stantaneously afforded  by  opening  with  drill  or  excavator 
into  the  pulp  chamber,  through  the  floor  of  the  carious  cavity 
which  generally  exists,  and  by  so  doing  the  gaseous  tension 
within  the  tooth  is  at  once  relieved.     The  opening  should 
be  kept  patent  by  a  plug  of  cotton  wool,  loosely  inserted  and 
changed  daily.     From  what  has  been  already  said  it  may 


GENERAL    PRACTITIONERS.  53 

readily  be  understood  that  the  death,  and  subsequent  pu- 
trefaction of  the  u'hole  of  the  dental  pulp  thus  brought  about 
may,  in  the  course  of  a  few  weeks,  produce  a  condition  of 
periodontitis  within  the  alveolar  socket. 

IV.  Alveolar  and  Facial  Neuralgia. — This  is  variable  in 
degree,  becoming  more  severe  when  the  general  health  is 
disturbed,  and  after  bodily  fatigue  and  want  of  food.  It  flies 
up  the  side  of  the  face,  into  the  neighbourhood  of  the  ear, 
or  downwards  towards  the  shoulder  and  arm.  There  may 
in  almost  all  cases  be  found  the  stumps  of  decayed  teeth, 
which  should  be  completely  removed  if  the  neuralgic  symp- 
toms are  persistent,  and  it  may  be  noted  that  most  cases 
of  what  is  termed  face-ague  and  tic  douloureux  have,  as  their 
exciting  cause,  a  dental  condition  such  as  that  described. 

The  four  preceding  conditions "  are  those  usually  accom- 
panying pain  in  and  around  the  dental  structures,  and  such 
admits  of  ready  relief  if  its  cause  be  recognised  and  the 
appropriate  remedy  adopted. 


54  DENTAL    SURGERY    FOR 


Chapter  VII. 
MECHANICAL  INJUEIES   TO   THE   TEETH. 

Wearing  down  of  the  Teeth  from  Friction  of  Mastica- 
tion. Hunter's  Denuding  Process.  Fracture  and 
Dislocation  of  a  Tooth  from  Violence. 

Towards  middle  life  the  cutting  edges  of  incisors,  and  the 
grinding  surfaces  of  the  masticating  teeth,  show  signs  of 
wearing  down,  and  the  rapidity  of  such  action  is  dependent 
upon  the  density  of  the  tooth  structure,  and  upon  the 
nature  of  the  food.  Among  savage  races,  who  live  mostly 
on  coarse  badly  prepared  materials,  we  see  such  extensive 
attrition  that  the  pulp  cavities  would  be  speedily  opened 
into,  did  not  a  development  of  secondary  dentine  within 
the  pulp  cavity  and  adherent  to  its  walls  prevent  such  a 
result. 

It,  is  also  not  unusual  to  find  among  middle  aged  per- 
sons a  deep  horizontal  well  polished  groove,  reaching 
almost  into  the  pulp  chamber,  across  the  outer  surfaces 
of  the  necks  of  incisor,  canine,  and  bicuspid  teeth.  This 
condition,  to  which  the  name  of  Hunter's  denuding  jwocess- 
has  been  applied,  results  from  the  friction  of  the  tooth- 
brush acting  upon  the  softer  cementum  of  the  neck  of  the 
tooth  which  has  become  exposed  by  the  commencing  re- 
cession of  the  gums.     From  this  last  cause  the  necks  ot 


GENERAL    PRACTITIONERS.  55 

the  teeth  are  towards  middle  life  frequently  laid  bare,  and 
their  less  durable  structures  are  liable  to  be  thus  damaged 
by  a  mechanical  cause,  aided  by  the  solvent  action  of  the 
fluid  of  the  mouth. 

The  surface  tenderness  which  is  often  associated  with 
this  action  may  be  relieved  by  a  frequent  application  of 
eau  de  Cologne  upon  wool ;  but  if  there  be  a  deep  cup-shaped 
cavity  in  the  grinding  surface  of  a  molar,  or  a  groove  upon 
the  neck  of  an  incisor  opening  almost  into  its  pulp-cham- 
ber, it  may  become  necessary  to  insert  a  metal  filling  in 
order  to  prevent  further  and  more  serious  damage  to  the 
tooth.  Moreover,  all  rapidly  cutting  tooth-powders,  such 
as  charcoal  or  pumice  powder,  should  be  at  once  discon- 
tinued, and  a  soft  brush  be  used  with  soap  and  chalk. 
These  last  only  should  indeed  be  employed  in  all  cases, 
and  if  used  twice  daily  will  be  quite  effective  in  keeping  the 
teeth  well  polished. 

One  or  more  teeth  may  be  fractured  by  a  blow  acting 
directly  upon  the  damaged  organs,  or  indirectly  through 
the  sudden  closure  of  the  lower  teeth  upon  the  upper,  as 
when  a  heavy  fall  is  sustained  upon  the  chin  in  the  hunt- 
ing field.  The  rough  fractured  surface  may  be  smoothed 
down  with  a  fine  file  if  the  damage  be  but  slight,  and  sur- 
face tenderness  may  be  relieved  by  an  application  of  eau 
de '  Cologne  or  nitrate  of  silver.  If  the  pulp  cavity  be 
broken  into  it  may  be  necessary  to  destroy  the  nerve 
with  arsenic,  and  subsequently  to  fill  the  tooth  or  to  file  it 
down  to  a  level  with  the  gum  ;  or  to  extract  its  fang  pre- 
paratory to  the  insertion  of  a  plate  carrying  an  artificial 
tooth. 


56  DENTAL    SURGERY    FOR 

An  incisor  tooth  may  be  partly  or  entirely  dislocated  by 
violence.     It  is  well  in  such  cases  to  replace  it  and  by  a 
careful  moulding  of  gutta-percha,  softened  in  warm  water, 
around  it  and  its  neighbours,  to  retain  it  in  situ,  in  the 
hope  that  it  may  again  become  firm  in  its  socket.     This  it 
will  very  frequently  do,  but  the  violence  to  which  it  has 
been  subjected  generally  destroys  its  dental-pulp,  which 
by  subsequent  decomposition  is  liable  to  induce  periodon- 
titis in  the  course   of  a  few  months.     For  this  last  the 
remedy,  as  before  pointed  out,  is  to  drill  a  small  opening 
through  the  neck  of  the  tooth  into  its  pulp  chamber  (see 
Chap.  V.,  rhizodontrophy) . 


GENERAL    PRACTITIONERS.  57 


Chapter  VIII. 

EXTBACTION   OF   TEETH  AND   STUMPS. 

Conditions  Necessitating  Extraction.  General  direc- 
tions as  to  the  Position  of  Operator  and  Patient. 
Concerning  the  Application  of  Forceps.  As  to  the 
Extraction  of  the  Tooth.  Accidents  during 
Extraction.  A  List  of  Instruments  needed  for 
Extraction.  Forceps,  their  General  Characters 
and  Various  Forms.  The  Elevator,  its  Description 
and  Mode  of  Using.     The  Screw  Extractor. 

Attention  to  some  practical  points  in  connection  with  this 
subject  is  necessary  to  the  medical  practitioner,  who, 
though  his  dental  practice  should  have  a  wider  range,  is 
likely  to  be  more  often  called  upon  to  use  the  forceps  than 
to  perform  other  dental  operations.  He  may  be  required 
to  relieve  irregularity  and  overcrowding  among  the  per- 
manent teeth  of  his  young  patients  by  the  judicious  re- 
moval of  one  or  more  dental  organs.  He  may  find 
extraction  to  be  the  only  means  by  which  he  can  cure 
the  toothache  for  which  his  patient  has  consulted  him, 
and  he  will  be  called  upon  to  adopt  this  treatment  when, 
from  the  necessities  of  the  case,  immediate  relief  from  severe 
pain  is  urgently  demanded.     This  last  may  be  required 


58  DENTAL    SURGERY    FOR 

when  extensive  caries,  or  fracture  from  direct  or  indirect 
violence,  lias  laid  bare  an  aching  dental  pulp ;  or  when 
acute  periodontitis  is  producing  alveolar  abscess.  He  will 
find  it  absolutely  necessary  to  extract  a  diseased  lower 
wisdom  tooth  which  is  causing  closure  of  the  jaws  through 
the  contraction  and  rigidity  it  may  have  induced  around  a 
temporo-maxillary  articulation.  Moreover,  to  cure  a  fistu- 
lous opening  through  the  cheek,  or  to  prevent  its  occur- 
rence when  threatened,  nothing  will  suffice  but  the 
complete  removal  of  the  lower  molar  which  he  will  pro- 
bably discover  to  be  the  cause  of  mischief.  He  may  be 
required  to  take  out  a  loose  temporary  tooth  the  fangs  of 
which,  sharpened  by  partial  absorption,  are  ulcerating 
through  the  gum  and  excoriating  the  cheek  or  lip  ;  extrac- 
tion may  be  needed  by  a  decayed  lower  molar  whose 
ragged  edges  are  threatening  to  produce  malignant  disease 
of  the  tongue;  or  for  the  cure  of  epulis  some  decayed 
stump,  underlying  the  tumour,  may  need  removal.  As 
the  teeth  become  loosened  by  the  absorption  of  alveolar 
process  and  recession  of  gums  that  accompany  other  senile 
changes,  extraction  will  from  time  to  time  be  required  to 
XDre-vent  them  from  proving  a  hindrance  to  mastication. 

The  foregoing  are  the  most  frequent  conditions  under 
which  the  use  of  forceps  is  indicated,  though  doubtless  from 
time  to  time  their  employment  will  be  required  from  other 
causes.  To  apply  them  effectively  it  is  necessary  to  place 
the  patient  in  a  solidly  made  chair  with  the  back  sufficiently 
low  and  so  cushioned  that,  if  the  removal  of  an  upper 
tooth  be  required,  the  head  may  be  readily  thown  back  and 
supported.      The  head  and  hand  of  the    operator  should 


GENERAL    PRACTITIONERS.  59 

never  be  allowed  to  intercept  the  light  which  should  fall 
directly  upon  the  tooth.  When  an  upper  tooth  on  either 
side  is  to  be  extracted,  he  should  stand  with  feet  well 
separated  by  the  right  hand  of  his  patient;  he  should  stand 
immediately  behind  the  latter  and  leaning  over  his  head 
when  about  to  take  out  a  lower  tooth  on  the  right  side ;  and 
when  extracting  any  lower  tooth  on  the  left  side  the  opera- 
tor should  place  himself  by  the  left  side  of  his  patient. 
The  attitude  of  the  operator  should  be  easy  and  uncon- 
strained, so  that  his  power  may  be  exerted  to  the  best 
advantage.  With  this  in  view  the  operating  arm  should 
be  held  fairly  close  to  the  side  that  its  movements  may  be 
well  regulated  and  under  control ;  the  head  of  the  patient 
raised  or  lowered ;  the  chin  thrown  upwards  or  depressed ; 
and  the  head  always  so  turned  towards  the  operator  that 
his  forceps  may  have  easy  access  to  the  tooth.  If  it  be  an 
upper  tooth  that  is  to  be  extracted  his  left  hand  must 
be  used  to  steady  the  upper  maxilla  during  application  of 
the  forceps,  and  to  aid  the  extraction  by  providing  an  oppos- 
ing force  to  the  traction  of  the  instrument.  To  effect  this 
he  should  firmly  grasp  with  fingers  and  thumb  the  alveolar 
process  on  either  side  of  the  tooth  he  is  about  to  remove. 
If  the  tooth  be  in  the  lower  jaw  the  left  hand  should  be 
used  to  prevent  all  rocking  and  depression  of  the  inferior 
maxilla  by  rigidly  securing  it  between  the  fingers  and 
thumb. 

In  applying  forceps  to  a  tooth  with  a  view  to  its  extrac- 
tion the  operator  should  determine  to  insert  their  blades  as 
deeply  into  the  socket  and  as  far  up  the  fang  as  is  practic- 
able.    An  exception  to  this  holds  good  when  the  removal  of 


60  DENTAL    SURGERY    FOR 

a  temporary  molar  is  demanded,  since  the  crown  of  the 
underlying  permanent  bicuspid  may  be  grasped  by  the  in- 
strument if  this  be  used  too  vigorously.  In  the  application 
of  forceps  these  points  should  be  regarded.  1.  The  tooth 
should  be  grasped  very  lightly  between  the  blades  of  the  in- 
strument in  order  that  the  latter  may  travel  freely  up  its 
fang.  2.  The  forceps  should  be  pushed  freely  and  vigor- 
ously home.  3.  During  this  process  the  instrument  should 
receive  the  slightest  possible  rotation  on  its  long  axis.  This 
should  hardly  amount  to  more  than  a  tremulous  movement, 
but  it  suffices  to  convince  the  operator  that  the  blades  are 
not  gripping  the  neck  of  the  tooth  so  tightly  as  to  prevent 
them  from  travelling  up  it.  4.  The  long  axis  of  the  blades 
of  the  forceps  should  be  continuous  with  or  in  the  same 
direction  as  the  long  axis  of  the  tooth.  If  this  be  disregarded 
the  margin  of  the  blades  may  impinge  upon  a  neighbouring 
tooth,  which  by  its  resistance  may  greatly  hamper  the  opera- 
tor while  performing  extraction.  This  precaution  is  very 
necessary  when  an  upper  bicuspid  has  to  be  removed.  5. 
The  eye  of  the  operator  should  be  fixed  upon  the  tooth  and 
it  should  never  be  lost  sight  of  throughout  the  operation. 

,Ihe  neck  of  the  tooth  being  thus  securely  and  firmly 
grasped,  extraction  should  be  effected  by  steady  and  contin- 
uous traction.  Combined  with  this  should  be  partial  rotation 
on  its  long  axis,  if  it  be  a  single  fanged  tooth,  as  an  upper  or 
lower  incisor,  canine,  or  bicuspid,  with  also  a  slight  amount 
of  rocking  or  lateral  movement  applied  judiciously  and  with 
great  caution.  Be  it  born  in  mind  that  the  risk  of  break- 
ing a  single  fanged  tooth  is  greatly  increased  when  this 
rocking  movement  is  applied,  but  in  some  cases  it  is  quite 


GENERAL    PRACTITIONERS.  6l 

necessary  to  adopt  a  certain  amount  of  it.  If  it  be  an 
upper  or  lower  molar,  the  tooth  should  be  freely  rocked  in- 
wards and  outwards  while  forcible  traction  is  being  em- 
ployed, and  with  such  teeth  any  rotation  upon  the  long 
axis  is  of  course  prohibited  by  the  arrangement  of  their 
fangs. 

There  are  certain  untoward  occurrences,  by  no  means 
uncommon  in  tooth  extraction,  which  must  be  noted  as 
follows. 

A.  The  tooth  to  which  forceps  are  applied  may  break.  This 
accident  usually  results  from  one  of  the  following  causes. 
1.  The  long  continued  progress  of  decay  may  have  almost 
entirely  softened  the  dentine  of  which  its  fangs  are  com- 
posed.    Added  to  this  may  be  the  glueing  of  their  exteriors 
into  their   sockets  by  inflammatory  exudation  before  re- 
ferred to  {see  Chap.  V.)   These  conditions  prevent  the  blades 
of  forceps  from  travelling  down,  and  favour  the  collapsing 
of  the  walls  of  the  stumps  as  soon  as  pressure  is  brought  to 
bear  upon  them.     In  such  cases  it  is  well  to  commence  by 
using  the  elevator  to  partially  dislodge  them,  and  the  forceps 
may  then  complete  their  removal.    In  this  state  do  we  often 
find  a  carious  lower  molar  with  which  a  fistulous  opening 
through  the  face  is  connected.     2.  The  fangs  may  be  con- 
siderably curved  and  clinging  tenaceously  to  septa  of  bone  or 
to  fangs  of  neighbouring  teeth.     3.  The  fangs  may  have,  as 
the  result  of  chronic  inflammatory  action,  become  enlarged 
or   exostosed,  and  so  rivetted  into  the   alveolar  process. 
4.  The  dentine  may  have  as  the  result  of  senile  changes 
become  almost  as  brittle  as  glass,  and  on  this  account  it  is 
well  to  be  on  one's  guard  when  dealing  with  the  teeth  of 


62  DENTAL    SURGERY    FOR 

elderly  persons.  From  any  of  these  causes  a  tooth  or 
stump  may  break,  and  blame  in  many  cases  is  not  to  be 
attributed  to  the  operator  if  it  do  so.  He  should  al- 
ways, before  applying  his  forceps,  ascertain  the  mobility 
of  the  tooth  in  its  socket  by  rocking  it  carefully  and 
slightly  to  and  fro  with  a  strong  excavator  resting  against 
the  inner  or  outer  wall  of  its  crown.  If  fracture  occur 
during  extraction,  he  should  wipe  away  with  a  plug  of 
absorbent  wool  on  the  end  of  an  excavator  any  blood 
which  may  conceal  the  surface  of  the  stump,  and  then 
attempt  its  removal  with  a  finer  or  narrower  instrument. 
If  he  now  fail  after  a  reasonable  attempt,  let  him  desist, 
since  a  prolonged  operation  serves  but  to  exhaust  his 
patient,  and  prevents  his  own  success  in  any  subsequent 
operation  he  may  enter  upon.  If,  as  the  result  of  the  fracture, 
there  be  apparent  a  vital  and  intensely  sensitive  exposed 
dental  pulp,  this  may  be  removed  as  completely  as  possible 
by  passing  down  the  fang  a  finely  barbed  nerve  extractor 
(vide  fig.  18,  Chap.  Y).  The  stump,  if  it  cannot  be  removed, 
may  be  allowed  to  remain  with  the  probability  that  it  will 
now  give  no  more  trouble,  since  the  nerve  which  was  pre- 
viously aching  has  been  removed,  and  being  healthy  and 
free  from  septic  change  it  is  not  likely  to  set  up  perio- 
dontitis. If  the  motive  for  the  attempted  extraction  be  the 
relief  of  periodontitis,  this  condition  will  be  relieved  by 
the  complete  opening  of  the  fang  canals  and  the  free 
escape  thus  given  to  imprisoned  gas  by  the  breaking  off 
of  the  crown  of  the  tooth.  The  patient  may  be  further 
consoled  by  an  assurance  that  after  a  year  or  two  the  pro- 
gress of  absorption  both  of  fang  and  alveolar  process  will 


GENERAL    PRACTITIONERS.  63 

probably  render  the  removal  of  the  broken  stump  compara- 
tively easy. 

B.  While  extracting  a  lower  molar  an  upper  incisor  may 
be  broken  by  the  back  of  the  forceps.  This  results  from 
the  sudden  parting  of  the  tooth  from  its  socket  after  a  pro- 
longed effort  has  somewhat  exhausted  the  muscular  power 
of  the  operator.  Guard  against  this  by  keeping  the  opera- 
ting arm  well  under  control,  and  by  intently  watching  for 
the  moment  when  the  tooth  is  about  to  sever  connection 
with  its  socket. 

C.  A  tooth  may  be  taken  out  other  than  that  which  it  was 
designed  to  extract.  This  can  result  only  from  wrant  of 
care,  and  should  be  guarded  against  by  closely  watching 
the  forceps  and  the  tooth  they  are  enclosing  throughout 
the  whole  operation.  During  hurried  extractions  under 
nitrous  oxide  this  misfortune  is  liable  to  occur,  when  the 
instrument  is  applied  within  a  moment  of  the  removal  of 
the  face-piece  by  an  operator  whose  haste  and  nervousness 
may  prevent  him  from  duly  observing  the  parts  with  which 
he  is  dealing. 

D.  The  alveolar  process  may  be  fractured,  and  indeed  it 
is  very  common  to  find  a  small  fragment  of  the  outer  al- 
veolar plate  adherent  to  the  fangs  of  a  molar  after  it  has 
been  removed.  More  than  this  has  not  happened  within 
my  experience,  but  a  separation  of  the  intermaxillary  bone 
from  the  superior  maxilla  during  removal  of  an  upper  in- 
cisor, and  of  transverse  fracture  of  the  ramus  of  the  lower 
jaw  while  a  lower  tooth  was  being  extracted,  have  been  re- 
corded by  Mr.  Salter.  The  accidents  occurred  in  both  cases 
to  operators  who  possessed  such  skill  and  knowledge  as  to 


64  DENTAL    SURGERY    FOR 

make  it  certain  the  like  may  in  some  conditions  be  inevit- 
able. Apart  from  this,  however,  must  be  regarded  the 
breaking  off  of  the  tuberosity  of  the  upper  maxilla  during  the 
the  use  of  an  elevator  for  removal  of  an  upper  wisdom 
tooth,  For  extraction  of  this  last,  forceps  should  be  used, 
and  the  powerful  leverage  afforded  by  the  former  in- 
strument served  in  a  case  that  came  under  my  notice  a 
few  years  since  to  break  away,  with  the  upper  third  molar 
which  was  extracted,  a  mass  of  spongy  bone  in  size  as  large 
as  a  walnut. 

E.  The  gum  may  be  lacerated  during  removal  of  a  lower 
second,  or  third  molar,  through  its  occasionally  strong  ad- 
hesion to  the  neck  of  the  tooth.  If  this  be  the  case  a 
scalpel  should  be  used  to  divide  it  before  the  molar  is  entirely 
withdrawn  from  its  socket. 

F.  The  tongue  or  cheek  may  be  punctured,  and  a  large 
blood  vessel  thus  opened,  by  the  slipping  of  an  elevator. 
The  firm  pressure  of  the  end  of  the  first  finger  of  the 
operating  hand  upon  the  blade  within  one  quarter  of 
an  inch  of  its  extremity,  at  the  moment  of  introduction, 
and  then,  as  it  is  being  thrust  into  the  alveolus,  upon  the 
tooth  to  be  taken  out,  or  upon  its  fulcrum,  will  suffice  to 
prevent  this  mishap. 

G.  The  extracted  tooth  or  stump  may  slip  from  the 
grasp  of  the  instrument  and  passing  into  the  trachea  may 
cause  much  trouble.  This  is  an  accident  which  those 
operating  upon  an  anaesthetised  patient  should  guard 
against  by  carefully  folding  a  mouth-napkin  within  the 
mouth  behind  the  teeth  or  stumps  that  are  about  to  be 
removed. 


GENERAL    PRACTITIONERS.  65 

H.  Persistent  haemorrhage  after  extraction,  or  coming  on 
within  a  few  hours  of  the  operation,  may  need  prompt  at- 
tention. The  firm  blood  clot  which  may  often  be  found 
concealing  the  bleeding  socket  and  its  neighbouring  teeth 
should  be  vigorously  wiped  away  with  a  plug  of  wool  on  an 
excavator;  a  strip  of  dry  lint,  J  of  an  inch  wide  and  about  6 
inches  long,  should  then  be  plugged  into  the  socket,  being 
condensed  tightly  and  carried  down  completely  to  its  bottom, 
with  the  aid  of  the  excavator.  Over  the  plug  should  be  ap- 
plied a'compress  of  lint,  and  on  this  the  jaws  should  be  kept 
tightly  closed  for  a  few  hours.  In  this  way  the  bleeding 
may  with  certainty  be  controlled,  and  though  the  compress 
may  be  changed  daily,  the  plug  within  the  socket  should 
remain  undisturbed  for  three  or  four  days.  In  arresting 
haemorrhage  under  these  circumstances  dry  lint  will  be  found 
more  effective  than  that  moistened  with  any  fluid  styptic, 
such  as  Tinct.  Ferri  Perchlor. 

A  complete  equipment  of  instruments  for  extraction 
should  include  eight  forceps,  one  elevator,  and  one  screw 
extractor  and  drill  for  the  latter,  and  with  less  than  these 
a  practitioner  will  hardly  be  enabled  to  deal  with  all  cases 
presenting  for  treatment. 

The  eight  forceiDS  should  have  these  characters.  Their 
handles  should  be  strong,  unyielding,  and  quite  without 
spring,  which  tends  to  prevent  an  operator  from  judging  ac- 
curately of  the  amount  of  pressure  he  is  applying  to  a  tooth. 
Their  joints  should  be  strong,  and  without  any  play,  which, 
if  it  occur  after  considerable  use,  should  be  remedied  by 
careful  tightening  up  of  the  central  rivetted  screw.  A  loose 
joint   causes   much  inconvenience  during  extraction,  and 

F 


66  DENTAL    SURGERY    FOR 

while  wrenching  the  fangs  from  their  sockets,  since  it  allows 
the  blades  to  slide  to  and  fro  over  the  sides  of  the  tooth. 
Care  should  be  taken  that  water,  when  cleansing  the  for- 
ceps, does  not  enter  its  joint,  and  the  latter  should  be 
occasionally  oiled  that  it  may  work  freely  and  without  any 
rigidity.  The  blades  should  be  well  tempered,  being  neither 
so  soft  as  to  bend  or  splay  out  at  their  edges,  nor  so  hard 
as  to  chip  or  fly.  Also  the  space  between  them,  towards 
the  joint,  should  be  wide  enough  to  enable  them  to  close 
firmly  upon  the  neck  of  a  tooth  without  coming  in  contact 
with  its  crown.  The  stock  of  forceps  should  consist  of  the 
following. 

Fig.   19. 


Upper  incisor  and  canine  forceps. 

One  pair  of  'upper  incisor  and,  canine  forceps.  It  will 
be  seen  that  the  long  axis  of  the  handles  of  these  is 
not  quite  continuous  in  the  same  line,  but  is  set  at  a 
slight  angle  with  the  long  axis  of  their  blades.  In  applying 
them  to  an  upper  front  tooth  they  should  be  so  placed  that 
their  handles  incline  towards  the  patient's  chin  rather  than 
from  it.  To  summarize  the  directions  before  given,  remem- 
ber in  their  application  to  force  them  well  up  the  neck  of 
the  tooth.  Ensure  this  by  grasping  the  latter  lightly, 
regulating  the  pressure  by  firmly  pressing  the  ball  of 
the  thumb  of  the  operating  hand  into  the  space  between 


GENERAL    PRACTITIONERS.  67 

the  handles.  Also  while  forcing  them  up  within  the  socket 
give  them  a  slight  tremulous  movement,  or  one  of  partial 
rotation  upon  their  long  axis,  amounting  to  about  -£%  of  a 
circle,  so  that  the  sharp  cutting  edges  of  their  blades  shall 
sever  the  membranous- connections  between  the  fang  and  its 
socket.  Extraction  will  be  performed  by  steady  continuous 
traction,  increasing  gradually  in  amount,  during  which  the 
fang,  being  firmly  and  cautiously  grasped,  may  be  slightly 
rotated  on  its  long  axis.  Any  rocking  movement,  to  and 
fro,  or  in  an  antero-posterior  direction,  is,  as  before  men- 
tioned, here  injudicious.  Efforts  in  this  direction  should 
at  any  rate  be  applied  with  much  circumspection  and  only 
when  traction  with  rotation  does  not  promise  to  produce  the 
desired  result.  The  operation  should  not  be  hurried,  and 
if  the  fang  show  signs  of  giving  way  the  grasp  of  the  in- 
strument should  be  relaxed  and  it  should  be  thrust  more 
deeply  into  the  socket.  What  is  applicable  to  these  forceps 
may  be  held  to  apply  equally  to  those  intended  for  the  re- 
moval of  lower  front  teeth  and  of  upper  and  lower  bicus- 
pids. 

Fig.  20. 


Upper  bicuspid  forceps  for  either  side. 

One  pair  of  upper  bicuspid  forceps  for  either  side.      The  use 
of  these  should  be  confined   to   the   extraction   of  upper 

f2 


68  DENTAL    SURGERY    FOR 

bicuspid  teetli,  of  entirely  detached  molar  fangs,  and  occa- 
sionally of  upper  wisdom  teeth.  They  should  never  be 
employed  for  the  removal  of  badly  decayed  upper  first  or 
second  molars,  whose  fangs  are  still  united. 


Fig.  21. 


Forceps  for  lower  incisors,  canines  and  bicuspids. 


One  pair  of  forceps  for  lower  incisors,  canines  and  bicuspids. 
These  are  of  much  service  also  in  the  extraction  of  greatly 
decayed  lower  molars,  which  threaten  to  be  fractured  if 
grasped  by  the  ordinary  lower  molar  forceps.  With  the 
former,  one  fang,  usually  the  anterior,  may  be  grasped 
deeply  in  the  alveolus  and  removed  separately ;  or,  as  often 
happens,  with  the  posterior  fang  attached  to  it.  It  should 
be  noted  that  the  second  permanent  or  twelve  year  old 
molars  are  more  rigidly  fixed  in  the  maxillae  than  are  the 
first  or  six  year  old  molars.  It  follows  therefore  that  the 
former,  when  greatly  decayed,  are  more  liable  than  the 
latter  to  fracture  when  the  ordinary  molar  or  double  for- 
ceps (to  be  spoken  of  later  on)  are  applied  to  them.  For 
extraction  therefore  of  second  permanent  molars,  the  lower 
bicuspid,  or,  as  they  are  sometimes  termed,  stump  forceps, 
are  of  considerable  value.    When  one  fang  has  been  de- 


GENERAL    PRACTITIONERS. 


69 


taclied  and  removed,  but  little  difficulty  will  usually  be 
encountered  in  taking  out  also  the  remaining  fang. 

One  pair  of  forceps  for  upper  right  molars.  The  tang  pro- 
jecting from  one  blade  is  inserted  between  the  two  outer 
fangs,  and  the  neck  of  the  tooth  being  rigidly  grasped, 


Fig.  22. 


Forceps  for  upper  right  molars. 


well  within  the  socket,  should  be  steadily  rocked  inwards 
and  outwards  while  forcible  traction  is  being  exercised. 
No  movement  of  rotation  is  admissible  during  extrac- 
tion of  upper  and  lower  molars,  owing  to  the  arrangement 
of  their  fangs.  An  upper  wisdom  tooth,  if  not  too  firmly 
rooted,  may  be  readily  removed  by  upper  molar,  or  stout 
bicuspid  forceps.  If  it  be  very  rigid  and  unyielding,  it  is 
well  to  commence  by  moving  it  slightly  in  its  socket  with 
the  aid  of  an  elevator,  which  should  be  thrust  in  between  it 
and  the  second  molar.  The  use  of  the  elevator  in  this 
situation  requires  considerable  care,  owing  to  the  liability 
thus  encountered  of  breaking  away  the  tuberosity  of  the 
superior  maxilla,  and  the  extraction  of  the  tooth  is  to  be 
completed  with  the  forceps. 


7o 


DENTAL    SURGERY    FOR 


One  pair  of  forceps  for  upper  left  molars.  The  tang  pro- 
jecting from  one  blade  is  inserted  between  the  two  outer 
fangs. 

Fig.  23. 


Forceps  for  upper  left  molars. 

One  pair  of  lower  molar  forceps  for  either  side  of  the  mouth. 
Each  blade  presents  a  projecting  tang  which  should  be 
inserted  between  the  two  fangs  of  the  tooth.      If  the  latter 

Fig.  24. 


Lower  molar  forceps  for  either  side  of  the  mouth. 


be  fairly  solid  and  resisting  these  should  be  used  in  prefer- 
ence to  the  lower  stump,  or  single  fang  forceps,  since  they 
afford  a  more  secure  and  complete  grasp  of  the  tooth.  As 
the  long  axis  of  lower  molar  teeth  is  frequently  directed 
upwards  and  somewhat  inwards,  the  operator  should 
guard  against  depressing  the   handle  of  the  forceps  too 


GENERAL    PRACTITIONERS. 


71 


freely,  by  doing  which  he  may  at  any  time  readily  break  off 
the  crown  of  the  tooth.  If  the  lower  molar  be  at  all 
tilted  inwards,  he  should  aim  at  lifting  it  upwards  and  in- 
wards at  the  time  he  is  engaged  in  rocking  it  freely  inwards 
and  but  slightly  outwards. 

Fig.  25. 


Upper  stump  forceps. 

One  pair  of  upper  stump  forceps.  These  are  of  use  when 
searching  for  deeply  buried  single  fangs,  and  being  of 
somewhat  delicate  construction  should  not  be  too  severely 
taxed. 

Fig.  26. 


Lower  stump  forceps. 

One  pair  of  lower  stump  forceps.  These  resemble  those 
in  fig.  21.  Their  blades,  however,  are  somewhat  longer, 
are  more  delicate,  and  close  more  completely  at  their  cut- 
ting edges.    . 

The  Elevator  should  be  strong  and  unyielding.  Its 
length,  inclusive  of  handle  and  blade,  should  be  from  five 
to  six  inches.     The  handle  should  possess  a  smooth  broad 


72  DENTAL    SURGERY    FOR 

end,  that  the  palm  of  the  hand  may  not  be  injured  when 
using  it  forcibly.  The  blade  should  be  two  inches  long ; 
and,  for  its  lower  inch,  it  should  be  flat  on  one  side, 
convex  on  the  other,  and  one  quarter  of  an  inch  wide. 
Its  extremity  should  possess  a  sharp  cutting  edge,  and  be 
neither  pointed  nor  flat,  but  gently  rounded.  All  spear 
and  spoon  shaped  elevators  are  to  be  avoided  ;  also,  the  in- 
strument should  be  straight  throughout,  without  curve  or 
bend  of  any  nature. 

The  elevator  is  of  great  value  for  extraction  of  lower 
wisdom  teeth  and  of  firmly  implanted  stumps.  It  can  be 
employed  only  when  there  is  a  vacant  space,  or  portion  of 
maxilla  free  from  any  stump  or  tooth,  immediately  adjacent 
to  the  tooth  for  removal  of  which  it  is  to  be  used  ;  and 
for  extraction  of  upper  wisdom  teeth  it  is  rarely  to  be  used, 
owing  to  the  liability  of  fracturing  the  tuberosity  of  the 
upper  maxilla.  It  should  be  inserted  forcibly  into  the 
alveolus,  alongside  and  in  front  of  the  tooth  on  which  it 
is  to  operate,  with  its  flat  face  adjacent  to  the  latter,  and 
its  convex  side  in  contact  with  the  fulcrum.  Its  point 
should  be  directed  during  insertion  downwards  and  in- 
wards, so  that  the  long  axis  of  the  instrument  is  about 
half  way  between  the  horizontal  and  the  perpendicular. 
The  elevator  can  be  used  effectively  only  if  there  be  some 
strong,  firmly  implanted  tooth,  against  which  it  can  rest, 
as  on  a  fulcrum ;  and  if  it  be  remembered  that  the  ele- 
vator is  used  only  as  a  lever  of.  the  first  order,  the  need  for 
this  rigidity  in  its  fulcrum  must  be  apparent,  since  the  pres- 
sure bearing  upon  the  latter  will  be  the  sum  of  the  force  ap- 
plied by  the  operator's  hand,  and  of  the  resistance  offered  by 


GENERAL    PRACTITIONERS. 


73 


the  tooth  which  is  being  extracted.  Usually  it  will  be  found 
needful  that  the  fulcrum  should  be  in  front  of  the  tooth  that 
is  to  be  taken  out,  but  this  can  hardly  be  laid  down  as  a  rule. 


Fig.  27. 


Fig.  28. 


Diagrams  of  Elevator — front  and  side  views.   The  blade  being  the  exact 
size,  the  handle  should  be  four  inches  long. 


During  the  insertion  of  the  blade  into  the  alveolus,  the  end 
of  the  first  finger  of  the  operating  hand  must  be  pressed  firm- 
ly upon  it,  within  half  an  inch  of  its  end,  and  also  upon  the 
side  of  the  fulcrum,  or  of  the  tooth  to  be  extracted.  Thus 
any  puncturing  of  the  tongue  or  cheek  may  be  quite  pre- 
vented in  the  event  of  a  slip,  a  by-no-means  unusual  event, 


74 


DENTAL    SURGERY    FOR 


since  the  force  needed  to  insert  the  instrument  is  fre- 
quently very  great.  After  the  insertion  of  the  blade  its 
handle  should  be  carried  forward  towards  the  median  line. 
At  the  same  time  the  instrument  should  be  slightly  rotated 
on  its  long  axis,  so  that  the  lower  edge  of  its  blade  may 
tend  to  lift  up  and  loosen  the  stump  from  its  socket.  Dur- 
ing these  operations  the  eye  should  be  fixed  intently  upon 
the  fulcrum,  which  may,  if  care  be  not  taken,  readily  start 
from  its  position.  Thus  used,  the  elevator  serves  to  raise 
and  slightly  detach  a  tooth,  but  for  the  completion  of  its 
extraction,  which  is  thus  rendered  an  easy  task,  the  for- 
ceps may  be  required.  For  the  removal  of  lower  wisdom 
Fia.  29.  teeth  the  elevator  is  very  serviceable, 

and  it  should  then  be  thrust  freely 
into  the  alveolar  process  between  the 
second  and  third  molars. 

The  Screw  Extractor  is  of  use  for 
removal  of  decayed  stumps  of  upper 
incisors  or  canines.  The  fangs  gene- 
rally need  to  be  opened  up  with  a 
conical  four- sided  drill,  passed  up  the 
fang  canal,  and  rotated  between  the 
anger  and  thumb ;  after  which  the 
instrument  may  be  carefully  screwed 
into  the  fang,  which  should  be  re- 
moved by  gentle  traction  and  rock- 


Diagram  of  a  screw  ex- 
tractor for  removal  of 
stumps  of  upper  incisors 
and  canines. 


ing. 


GENERAL    PRACTITIONERS.  75 


Chapter  IX. 

ANESTHETICS.     PKEPARATION  OF  THE  MOUTH 
FOR  FRAMES.     SALIVARY  CALCULUS. 

Nitrous  Oxide,  Chloroform,  and  Ether  are  employed  to 
prevent  pain  during  extractions.  Inasmuch  also  as  they 
lessen  the  shock  of  an  operation  they  are  beneficial  when 
dealing  with  children  and  those  whose  health  is  enfeebled. 
Nitrous  oxide  is  now  supplied  in  a  liquid  form,  condensed 
by  pressure  and  cold  into  strong  wrought  iron  bottles, 
whence  it  is  liberated  into  the  bag  from  which  it  is  to  be 
inhaled.  It  is  an  anaesthetic  well  suited  for  minor  extrac- 
tions, and  may  safely  be  re -inspired  when  a  second  or 
third  tooth  has  to  be  removed.  It  may  be  applied  to 
patients  of  all  ages,  but  is  very  suitable  for  young  healthy 
persons  fairly  free  from  nervousness.  It  has  great  value 
when  anaesthesia  is  needed  by  one  whose  heart  is  enfeebled 
from  age  or  ill-health,  and  then  should  be  greatly  preferred 
to  chloroform,  since  it  acts  as  a  stimulant  to  the  weak 
organ,  while  the  latter  tends  to  depress  its  action.  Ner- 
vous, hysterical  girls,  will  frequently  not  take  "  gas  "  well, 
and  for  such  chloroform  should  be  used,  and  will  usually 
be  found  quite  safe  and  efficient.  A  sine  qua  non  in  the 
employment  of  nitrous  oxide  is  a  free  and  full  expansion 
of  the  chest  during  inspiration,  and  this  the  highly  strung 
nervous  patient  is  frequently  quite  unable  to  effect.      It 


j6  DENTAL    SURGERY    FOR 

may  be  breathed  until  blueness  of  the  face  and  commenc- 
ing stertor  indicate  that  the  right  degree  of  insensibility 
has  been  attained.  This,  if  the  mask  fit  so  accurately 
that  no  air  be  introduced  with  the  inhaled  gas,  is  usually 
arrived  at  within  50  to  80  seconds  from  the  commencement 
of  inhalation.  The  extraction  should  of  course  be  per- 
formed as  rapidly  as  possible  after  withdrawing  the  mask, 
and  great  care  needs  then  to  be  taken  lest  the  tooth  slip 
from  the  grasp  of  the  forceps  down  the  trachea  of  the 
patient,  and  lest  a  like  accident  occur  with  the  gag  or 
prop  that  has  been  used  to  keep  the  jaws  apart.  To  pre- 
vent the  latter  a  short  piece  of  thin  twine  should  always  be 
attached  to  the  gag,  which  should  be  of  a  telescopic  or 
sliding  pattern. 

Fig.  30. 


A  telescopic  gag  or  mouth  prop  for  use  during  inhalation  of  nitrous  oxide. 
It  should  be  placed  between  the  front  teeth  before  the  gas  is  inhaled. 

Chloroform  is  useful  when  many  teeth  have  to  be  ex- 
tracted, or  when  from  nervousness  and  absence  of  deep 


GENERAL    PRACTITIONERS. 


77 


breathing  the  gas  is  contra-indicated.  In  a  word,  with 
a  weak  heart  use  gas  rather  than  chloroform,  and  for 
a  nervous  hysterical  female  employ  chloroform  rather  than 

Fig.  31. 


A  mouth  opener  to  be  used  with  the  administration  of  chloroform. 

jas.      The   administration  of  chloroform  for  dental  pur 


78  DENTAL    SURGERY    FOR 

poses  should  never  be  pushed  to  any  extent,  and  before 
stertor  and  relaxation  of  the  muscles  show  that  the  third 
stage  of  anesthesia  has  been  reached,  the  mouth  should  be 
forcibly  opened  by  a  powerful  screw  gag  placed  between 
the  upper  and  lower  bicuspid  teeth.  The  gag  should  be 
held  by  an  assistant  between  the  bicuspids  while  the  oper- 
ation is  completed,  and  thus,  while  the  sense  of  pain  is 
dulled  or  entirely  removed,  we  avoid  •  causing  that  nausea 
and  prostration  which  generally  follow  upon  a  large  use 
of  chloroform. 

Ether  is  used  at  times  for  patients  of  middle  age,  but  for 
dental  purposes  is  not  very  convenient.  It  causes  great 
excitement,  salivation,  and  bronchial  irritation,  also  its 
pungent  vapor  is  apt  to  inconvenience  the  operator. 

The  undesirability  of  employing  any  anaesthetic,  be  it  gas, 
ether,  or  chloroform,  without  the  presence  and  assistance 
of  a  companion,  who  should  be  a  qualified  medical  practi- 
tioner, needs  hardly  to  be  indicated. 

The  'preparation  of  the  Mouth  for  the  Insertion  of  Frames. — 
Artificial  teeth  are  now  made  of  mineral  materials  only, 
and  are  carried  on  a  base  of  either  gold  or  vulcanite. 

They  are  worn  for  the  sake  of  appearance,  and  to  prevent 
lisping  during  speech,  as  when  an  artificial  incisor  is 
adopted ;  to  restore  or  increase  power  of  mastication,  as 
when,  molars  and  bicuspids  are  inserted;  or  to  serve  as 
props  when  all  the  back  teeth  of  one  or  both  jaws  have 
been  lost.  Thus  they  prevent  the  lower  jaw  from  approxi- 
mating too  closely  to  the  upper,  and  so  directly  tend  to 
preserve  the  upper  front  teeth,  which  would  otherwise  be 
bitten  out  and  loosened  by  the  increased  pressure  upon 


GENERAL    PRACTITIONERS.  79 

their  back  surfaces  of  the  lower  incisors  and  canines. 
This  last  is  certainly  not  one  of  their  least  useful  duties. 
Further,  by  keeping  the  jaws  apart,  they  prevent  that  pro- 
trusion of  the  inferior  maxilla,  and  raising  of  the  chin 
towards  the  nose,  that  characterises  the  aged. 

After  deciding  from  any  of  the  foregoing  reasons  that 
frames   should  be  worn,  it  is  usually  desirable  that  any 
greatly   decayed,    or   very  loose  teeth,    or  tender  stumps 
should  be  removed  ;   and  after  such  extractions  an  interval 
of  from  a  day  or  two  to  six  months  should  elapse  before 
the  models  of  the  mouth  are  obtained  to  which  frames  are 
to  be  made.     The  wax  impression   should  indeed  not  be 
taken  until  absorption  of  the  alveolar  process  is  well  ad- 
vanced or  completed.     Only  a  short  delay,  however,  need 
occur  if  before  their  removal  the  extracted  teeth  have  been 
very  loose,  since  already  much  of  their  sockets  has  disap- 
peared ;  and  if  there  be  necessity  for  immediate  wearing  of 
artificial  teeth,  the  impressions   may  be   taken  within    a 
week  or  so  of  the  operation.      From  these  a  temporary 
frame  may  at  once  be  made,  to  be  replaced  by  one  of  a 
more  permanent  character  at  the  end  of  a  year  or  so,  when 
the  alveolar  ridge  has  settled  down  somewhat  to  its  ulti- 
mate level. 

Tartar  or  Salivary  Calculus. — This  earthy  deposit,  which 
consists  of  lime  salts  with  animal  matter,  is  found  to 
collect  around  the  teeth  under  these  circumstances. 

I.  At  the  back  of  the  lower  incisors  and  canines,  which  is 
a  part  of  the  mouth  always  escaping  that  friction  from  the 
tooth  brush  and  from  the  passage  of  food  during  mastica- 
tion, which  tends  to  polish  the  surface  of  the  teeth  and  to 
prevent  lodgment  thereon  of  calcareous  particles. 


80  DENTAL    SURGERY    FOR 

II.  Upon  and  around  any  masticating  tootli  which  from 
decay  has  become  tender  to  pressure  and  change  of  tem- 
perature, and  so  has  got  thrown  out  of  work.  Thus,  if 
from  a  tender  molar  the  side  of  the  mouth  on  which  it  is 
placed  is  unused,  the  buccal  and  lingual  surfaces  of  molars 
and  bicuspids  of  both  upper  and  lower  jaws  on  that  side 
will  shortly  become  much  coated  with  deposit,  and  its  occur- 
rence may  be  accounted  for,  as  in  the  previous  case,  by 
the  absence  of  the  cleansing  influence  of  friction. 

III.  Towards  middle  life  upon  the  necks  of  teeth 
which. from  absorption  of  the  alveolar  process  and  gum  are 
becoming  exposed,  and  probably  in  such  cases  the  growth 
of  the  deposit  is  but  a  sequence  to  the  absorption  and  in 
no  manner  its  cause. 

The  removal  of  tartar  may  be  readily  effected  by  detach- 
ing it  from  below  upwards  with  a  strong  excavator,  and  thus 
it  may  be  scaled  off  the  surface  of  the  teeth,  which  should 
if  loose  be  steadied  with  the  fingers  of  the  left  hand.  Its 
formation  is  undesirable  since  it  is  apt  to  induce  an  irri- 
tated state  of  the  gums  and  to  form  a  lodgment  for  par- 
ticles of  food. 


GENERAL    PRACTITIONERS. 


8l 


INDEX. 


A   BSORPTION    of   temporary 
**■  ■*■     fangs,  2 
Absorptive  papilla,  2 
Abortive  teeth,  12 
Antiseptic   treatment   of  fang 

canal,  38 
Anaesthetics  for  dental  operations, 

75 

Arsenic,  application  of,  35 
Artificial  teeth,  preparation  of  the 
mouth  for,  78 

reasons  for  employment  of,  78 

Attrition,  54 


/^  ARIES  of  crown  of  tooth,  28 
^-/      Caries  of  neck  of  tooth,  29 
Caries,  its  first  stage,  31 

—  its  second  stage,  36 

—  its  third  stage,  46 
Chloroform,  76 
Closure  of  jaws,  48 
Cryptogam,   Leptothryx  Buccalis, 

29 


T^vECAY  of  teeth,  causes  of,  28 
^-^     Decay  of  first  molars,  29 
Decay  of  temporary  teeth,  4 
Dilacerated  teeth,  12 
Dislocation  of  teeth,  56 


T7  LEVATOR,   description   and 
-■— '     use  of,  72 

Enamel,  defective,  28 
Eruption,  retarded,  10 

—  of  temporary  teeth,  1 

—  of  permanent  teeth,  6 
Ether,  78 

Excavators,  their  form  and  use,  24 
Extraction  of  teeth,  reasons  for,  57 

—  of  a  wrong  tooth,  63 

—  of  temporary  teeth,  4 

—  for  the  cure  of  irregularity,  15 

—  symmetrical,  16 


1/TLLING  of  teeth  temporarily, 

34 
Fistulous  opening  through  cheek, 


82 


DENTAL    SURGERY    FOR 


Forceps,  their  mode  of  using,  59 

—  their  general  characters,  65 
Fracture  of  a  tooth  by  forceps,  61 

—  of  alveolar  process  during  ex- 
traction, 63 


/"""*  AS  pressure  on  the  nerve,  52 


KJ 


Geminated  teeth,  12 


Gum,  lancing  of,  2 
Gum-boil,  44 

Gum,  laceration  of,  during  extrac- 
tion, 64 
Gutta-percha  as  a  filling,  34 


T  T^MORRHAGE    after     ex- 
-*-  -*■      traction,  65 
Honeycombed  teeth,  13 
Hunter's  denuding  process,  54 
Hutchinson's  teeth,  13 


1 


J 


RREGULARITY  in  positions 
of  teeth,  causes  of,  14 


AWS,  closure  of,  48 


L 


EPTOTHRYX  Buccalis,  29 


IV  /TECHANICAL     injuries     of 
**-■*     teeth,  54 

Mirror  for  mouth  examination,  26 
Myeloid  tumours  of  jaw,  10 


TVT  ERVE  devitalizing  by  arsenic 

^      35 
Nerve,  death  of,  37 

—  exposure  of,  35 

—  extraction  of,  38 
Neuralgia,  53 
Nitrous  oxide  gas,  75 


o 


DONTALGIA,  50 


"PERIODONTITIS,  acute,  41 
-*-        Periodontitis,  cause  of,  40 
Periodontitis,  chronic,  43 
Permanent    teeth,   to  distinguish, 
from  temporary,  8 


T)  EGULATING  plates,  17 
■*-^-     Rhizodontropy,  45 


SALIVARY  calculus,  79 
Screw  extractor,  use  of,  74 
Stopping  temporary  teeth,  4 
Strumous  teeth,  13 


GENERAL    PRACTITIONERS. 


83 


Supernumerary  teeth,  10 
Symmetrical  extraction,  16 
Syphilitic  teeth,  13 


npARTAR,  79 
■*■       Teeth,    eruption     of    tem- 
porary, 1 
Teeth,  decay  of  temporary,  4 
—  ulceration  through  gum  of  fangs 

of,  5 

Tic  doloureux,  53 
Tooth-ache,  50 
Torsion  of  teeth,  19 
Tooth  powder,  55 


T  T  LCERATION  through  gums 
^-^         of    fangs     of    temporary 
teeth, 5 


V 


■shaped  jaw,  22 


WEARING  down  of  crowns 
of  teeth,  54 
Wisdom  teeth,  eruption  of,  7 
extraction  of,  7 


62 


CATALOGUE  No.  7. 


A  CATALOGUE 


OF 


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THIRD  REVISED  EDITION. 
A  Compend  of  Human  Anatomy.     By  Samuel  O.  L. 
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A  Compend  of   the  Practice  of    Medicine,  especially 
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"  Part  of  a  series  of  small  but  valuable  text-books.  .  .  .  While 
the  work  is,  owing  to  its  therapeutic  contents,  more  useful  to  the 
medical  student,  the  pharmaceutical  student  may  derive  much  use- 
ful information  from  it." — N.  Y.  Pharmaceutical  Record. 

No.  7.    CHEMISTRY.    Revised  Ed. 

A  Compend  of  Chemistry.     By  G.  Mason  Ward,  m.d., 
Demonstrator  of  Chemistry  in  Jefferson  Medical  Col- 
lege, Philadelphia.    Including  Table  of  Elements  and 
various  Analytical  Tables. 
"  Brief,  but  excellent.  ...  It  will  doubtless  prove  an  admirable 

aid  to  the  student,  by  fixing  these  facts  in  his  memory.    It  is  worthy 

the  study  of  both  medical  and  pharmaceutical   students   in   this 

branch." — Pharmaceutical  Record,  New  York. 

No.  8.    VISCERAL  ANATOMY. 

A  Compend  of  Visceral  Anatomy.  By  Samuel  O.  L. 
Potter,  m.a.,  m.d.,  U.  S.  Army.   With  40  Illustrations. 

*#*  This  is  the  only  Compend  that  contains  full  descriptions  of  the 
viscera,  and  will,  together  with  No.  i  of  this  series,  form  the  only 
complete  Compend  of  Anatomy  published. 

No.  9.    SURGERY.     Second  Edition. 

A  Compend  of  Surgery;  including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations  and  other  opera- 
tions, Inflammation,  Suppuration,  Ulcers,  Syphilis, 
Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Eye, 
Bladder,  Testicles,  Anus,  and  other  Surgical  Diseases. 
By  Orville  Horwitz,  a.m.,  m.d.,  with  62  Illustra- 
tions.    Second  Edition.     Enlarged  and  Revised. 

Price  of  Each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  TQUIZ-COMPENDS?. 


No.  10.    ORGANIC  CHEMISTRY. 

JUST  PUBLISHED. 
A  Compend  of  Organic  Chemistry,  including  Medical 
Chemistry,  Urine  Analysis,  and  the  Analysis  of  Water 
and  Food,  etc.  By  Henry  Leffmann,  m.d.,  Pro- 
fessor of  Clinical  Chemistry  and  Hygiene  in  the  Phila- 
delphia Polyclinic ;  Professor  of  Chemistry,  Penn- 
sylvania College  of  Dental  Surgery ;  Member  of  the 
N.  Y.  Medico-Legal  Society.  Cloth.     $1.00 

Interleaved,  for  the  addition  of  Notes,  $1.25 

Nature  of  Organic  Bodies.  Transformations  under  various  con 
ditions.  Organic  Synthesis.  Homologous  and  Isomeric  Bodies 
Empirical  and  Rational  formulae.  Classification  of  Organic  Bodies 
Hydrocarbon.  Derivatives  of  Hydrocarbons,  Alcohols  and  Ethers 
Benzenes  and  Turpenes.  Fat  Acids,  Oils  and  Fats,  Sugars,  Gluco 
sides.  Cyanogen  Compounds,  Amines  and  Amides.  Alkaloids 
Ptomaines.  Animal  Chemistry.  Nutrition  and  Assimilation 
Food,  Water  and  Air.     Urinary  Analysis.     Index. 

The  Essentials  of  Pathology. 

BY  D.  TOD  GILLIAM,  M.D., 

Professor  of  Physiology  in  Starling  Medical  College,  Columbus,  O. 

With  47  Illustrations.    12mo.    Cloth.    Price  $2.00. 

***  The  object  of  this  book  is  to  unfold  to  the  beginner  the  funda- 
mentals of  pathology  in  a  plain,  practical  way,  and  by  bringing  them 
within  easy  comprehension  to  increase  his  interest  in  the  study  of 
the  subject.  Though  it  will  not  altogether  supplant  larger  works, 
it  will  be  found  to  impart  clear-cut  conceptions  of  the  generally 
accepted  doctrines  of  the  day,  and  to  prevent  confusion  in  the  mind 
of  the  student. 

A  POCKET-BOOK  OF 

PHYSICAL    DIAGNOSIS 

OF   THE 

Diseases  of  the  Heart  and  Lungs. 

A  MANUAL  FOR   STUDENTS  AND   PHYSICIANS. 
BY  DR.  EDWARD  T.  BRUEN, 

Demonstrator  of  Clinical  Medicine  in  the  University  of  Pennsyl- 
vania, Assistant  Physician  to  the  University  Hospital,  etc. 

Second  Edition,  Revised.    With  new  Illustrations.    12mo.    $1.50 

***The  subject  is  treated  in  a  plain,  practical  manner,  avoiding 
questions  of  historical  or  theoretical  interest,  and  without  laying 
special  claim  to  originality  of  matter,  the  author  has  made  a  book 
that  presents  the  somewhat  difficult  points  of  Physical  Diagnosis 
clearly  and  distinctly. 


STUDENTS'  MANUALS. 


GOODHART  AND  STARR  ON  DISEASES 
OF  CHILDREN.  A  Practical  Guide  for  Students. 
Demi-Octavo.  Cloth,  $3.00;  Leather,  $4.00. 

LANDOIS'      MANUAL      OF     PHYSIOLOGY. 

With  Special  Reference  to  Practical  Medicine.     Vol. 
1,  with  176  Illustrations.     8vo.  Cloth,  $4.50. 

Vol.  II.  Nearly  Ready. 

TYSON,  ON  THE  URINE.  A  Practical  Guide  to 
the  Examination  of  Urine.  For  Physicians  and  Stu- 
dents. By  James  Tyson,  m.d.,  Professor  of  Path- 
ology and  Morbid  Anatomy,  University  of  Pennsylva- 
nia. With  Colored  Plates  and  Wood  Engravings. 
Fourth  Edition.  i2mo,  cloth,  $1.50 

HEATH'S  MINOR  SURGERY.  A  Manual  of 
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London.     6th  Edition.     115  111.     i2mo,  cloth,  $2.00 

MACNAMARA,  ON  THE  EYE.  A  Manual  for 
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DULLES'  ACCIDENTS  AND  EMERGEN- 
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trated.    283  pages.     8vo. 

Paper  covers,  75  cents;  cloth,  $1.25 

ALLINGHAM,  ON  THE  RECTUM.  Fistulse, 
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Treatment.  By  Wm.  Allingham,  m.d.  Fourth  Re- 
vised and  Enlarged  Edition.     Illustrated.     8vo. 

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.       STUDENTS'  MANUALS  AND  LEXICONS. 

MARSHALL  AND  SMITH,  ON  THE  URINE. 

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shall, M.D.,  Chemical  Laboratory,  University  of  Penn- 
sylvania, and  Prof.  E.  F.  Smith.  Illus.  Cloth,  #1.00 

MEARS'  PRACTICAL  SURGERY.  Surgical 
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Jefferson  Med.  College.  227  Illus.    2d  Ed.     In  Press. 

KIRKE'S  PHYSIOLOGY.  A  Handbook  for  Stu- 
dents. Eleventh  Edition,  1884.  466  Illustrations. 
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TYSON,  ON  THE  CELL  DOCTRINE;  its  His- 
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MEADOWS'  MIDWIFERY.  A  Manual  for  Stu- 
dents. By  Alfred  Meadows,  m.d.  From  Fourth 
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WYTHE'S    DOSE    AND    SYMPTOM    BOOK. 

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PHYSICIAN'S  PRESCRIPTION  BOOK.  Con- 
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tion.        32mo,  cloth,  $1.00;  pocket-book  style,  $1.25 

POCKET  LEXICONS. 

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cine and  the  Collateral  Sciences.  Thirtieth  Edition. 
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LONGLEY'S    POCKET    DICTIONARY.      The 

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ROBERTS'  PRACTICE. 

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Long  Island  College  Hospital,  Yale  and  Harvard  Colleges, 

Bishop's  College,  Montreal,  University  of  Michigan,  and 

over  twenty  other  Medical  Schools. 

A  HANDBOOK  OF  THE  THEORY  AND  PRACTICE  OF 
MEDICINE.  By  Frederick  T.  Roberts,  m.d.,  m.r.c.p., 
Professor  of  Clinical  Medicine  and  Therapeutics  in  University 
College  Hospital,  London.     Fifth  Edition.     Octavo. 

CLOTH,  $5.00 ;  LEATHER,  $6.00. 
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Many  chapters  have  been  rewritten.  Important  additions  have  been 
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tal compendium  of  the  classified  knowledge  of  the  subject." — Prof. 
J.  Adams  Allen,  Rush  Medical  College,  Chicago. 

"  I  have  become  thoroughly  convinced  of  its  great  value,  and 
have  cordially  recommended  it  to  my  class  in  Yale  College." — 
Prof  David  P.  Smith. 

"  I  have  examined  it  with  some  care,  and  think  it  a  good  book, 
and  shall  take  pleasure  in  mentioning  it  among  the  works  which 
may  properly  be  put  in  the  hands  of  students." — A.  B.  Palmer, 
Prof,  of  the  Practice  of  Medicine,  University  of  Michigan. 

"  It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands, 
as  a  compendium  for  students  preparing  for  examination.  It  is 
thoroughly  practical,  and  fully  up  to  the  times." — The  Clinic. 

By  Same  Author. 
A  NEW  COMPEND  FOR  STUDENTS. 

ROBERTS'  NOTES  ONMATERIAMEDICA 

AND    PHARMACY. 

Just  Ready.     i2mo.     Cloth,  Price  $2.00. 

BIDDLE'S  MATERIA  MEDIGA. 

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Michigan,   College  of  Physicians  and  Surgeons,  Baltimore , 

Baltimore  Medical  College,  Louisville  Medical  College, 

and  a  number  of  other  Colleges  throughout  the  U.  S. 

BIDDLE'S  MATERIA  MEDICA.  For  the  Use  of  Students  and 
Physicians.  By  the  late  Prof.  John  B.  Biddle,  m.d.,  Profes- 
sor of  Materia  Medica  in  Jefferson  Medical  College,  Philadelphia. 
The  Ninth  Edition,  thoroughly  revised,  and  in  many  parts  re- 
written, by  his  son,  Clement  Biddle,  m.d.,  Past  Assistant 
Surgeon,  U.  S.  Navy,  assisted  by  Henry  Morris,  m.d. 

CLOTH,  $4.00  ;  LEATHER,  $4.75. 

"I  shall  unhesitatingly  recommend  it  (the  9th  Edition)  to  my 
students  at  the  Bellevue  Hospital  Medical  College. — Prof. 
A.  A.  Smith,  New  York,  June,  1883. 

"The  larger  works  usually  recommended  as  text-books  in  our 
medical  schools  are  too  voluminous  for  convenient  use.  This  work 
will  be  found  to  contain  in  a  condensed  form  all  that  is  most  valuable, 
and  will  supply  students  with  a  reliable  guide." — Chicago  Med.  yi. 

*#*  This  Ninth  Edition  contains  all  the  additions  and  changes  in 
the  U.  S.  Pharmacopoeia,  Sixth  Revision. 


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CARPENTER  ON  THE  MICROSCOPE  and  Its  Revelations 
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Plates    handsomely  printed.  Demi  8vo,  cloth,  $aoo 

FLOWER,  DIAGRAMS  OF  THE  NERVES  of  the  Human 
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GLISAN'S  MODERN  MIDWIFERY.  A  lext-book  129 
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Edition.     6x  Lithographic  Plates  and  n-yjood^f^ 

HEADLAND,  THE  ACTION  OF  MEDICINE  in  the  System. 

mSn^PSYCH^OGICAL  MEDICINE  8and  ffedfe 
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MEIGS  AND  PEPPER  ON  CHILDREN.  A  Practical  Trea- 

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use  on  i^c  gvo^  doth^  ^6qo  .  leather>  j7-00 

PARKES'  PRACTICAL  HYGIENE.     Sixth  Revised  and  En- 
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RIGBY'S  OBSTETRIC  MEMORANDA.        32m0,  cloth>  -5° 
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WILSON'S  HUMAN  ANATOMY.  General  and  Special. 
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WYTHE'S  MICROSCOPIST.  A  Manual  of  Microscopy  and 
Compend  of  the  Microscopic  Sciences  Fourth  Edition.  252 
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ACTON  ON  THE  REPRODUCTIVE  ORGANS.  Their 
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FOTHERGILL,  ON  THE  HEART.  Its  Diseases  and  their 
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HOLDEN'S  ANATOMY.        Fifth  Edition. 

Just  Ready. 

A  MANUAL  OF  THE  DISSECTION 

OF  THE  HUMAN  BODY. 

By  Luther  Holden,  m.d.,  Late  President  of  the  Royal  College 
of  Surgeons  of  England,  Consulting  Surgeon  to  St.  Bartholomews 
Hospital.  Fifth  Edition;  edited  by  John  Langton,  m.d.,  f.e.c.1. 
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REESE'S 
MEDICAL   JURISPRUDENCE 

AND  TOXICOLOGY. 

A  Text-book  of  Medical  Jurisprudence  and  Toxicology.  By 
John  J.  Reese,  m.  d.,  Professor  of  Medical  Jurisprudence  and 
Toxicology  in  the  Medical  and  Law  Departments  of  the  University 
of  Pennsylvania ;  Vice-President  of  the  Medical  Jurisprudence  So- 
ciety of  Philadelphia ;  Physician  to  St.  Joseph's  Hospital ;  Corres- 
ponding Member  of  the  New  York  Medico-legal  Society.  One 
Volume.    Demi  Octavo.    606  pages.    Cloth,  $4.00  ;  Leather,  $5.00. 

"  Professor  Reese  is  so  well  known  as  a  skilled  medical  jurist 
that  his  authorship  of  any  work  virtually  guarantees  the  thorough- 
ness and  practical  character  of  the  latter.  And  such  is  the  case  in 
the  book  before  us.  *  *  *  *  We  might  call  these  the 
essentials  for  the  study  of  medical  jurisprudence.  The  subject 
is  skeletonized,  condensed,  and  made  thoroughly  up  to  the  wants  of 
the  general  medical  practitioner,  and  the  requirements  of  prose- 
cuting and  defending  attorneys.  If  any  section  deserves  more  dis- 
tinction than  any  other,  as  to  intrinsic  excellence,  it  is  that  on  toxi- 
cology. This  part  of  the  book  comprises  the  best  outline  of  the 
subject  in  a  given  space  that  can  be  found  anywhere.  As  a  whole, 
the  work  is  everything  it  promises  and  more,  and  considering  its 
size,  condensation,  and  practical  character,  it  is  by  far  the  most 
useful  one  for  ready  reference  that  we  have  met  with.  It  is  well 
printed  and  neatly  bound. — N.  Y.  Medical  Record,  Sept.  13th,  1884. 


RICHTER'S  CHEMISTRY, 

A  TEXT-BOOK  of  INORGANIC  CHEMISTRY  for  STUDENTS. 

By  PROF.  VICTOR  von  RICHTER, 

University  of  Breslau, 

Authorized  Translation  from  the  Third  German  Edition, 

By  EDGAR  F.  SMITH,  M.A.,  Ph.D., 

Professor  of  Chemistry  in  Wittenberg  College,  Springfield,  Ohio  ; 
formerly  in  the  Laboratories  of  the  University  of  Pennsyl- 
vania; Member  of  the  Chemical  Society  of  Berlin. 

12mo.  89  Wood-cuts  and  Col.  Lithographic  Plate  of  Spectra.  $2.00 

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features  and  difficulties  we  have  to  contend  with  is  the  separate 
presentation  of  the  theories  and  facts  of  the  science.  These  are 
usually  taught  apart,  as  if  entirely  independent  of  each  other,  and 
those  experienced  in  teaching  the  subject  know  only  too  well  the 
trouble  encountered  in  attempting  to  get  the  student  properly  in- 
terested in  the  science  and  in  bringing  him  to  a  clear  comprehension 
of  the  same.  In  this  work  of  Prof,  von  Richter,  which  has  been 
received  abroad  with  such  hearty  welcome,  two  editions  having 
been  rapidly  disposed  of,  theory  and  fact  are  brought  close  together, 
and  their  intimate  relation  clearly  shown.  From  careful  observa- 
tion of  experiments  and  their  results,  the  student  is  led  to  a  correct 
understanding  of  the  interesting  principles  of  chemistry. 

In  preparation,  "ORGANIC  CHEMISTRY,"  By  the  same 
author  and  translator. 


YEO'S   PHYSIOLOGY. 

A  MANUAL  FOR  STUDENTS.     JUST  READY. 
300     CAREFULLY    PRINTED    ILLUSTRATIONS. 
FULL  GLOSSARY  AND  INDEX. 
By  Gerald  F.  Yeo,  m.d.,  f.r.c.s.,  Professor  of  Physi- 
ology in  King's  College,  London.    Small  Octavo.    750 
pages.     Over  300  carefully  printed  Illustrations. 

PRICE,  CLOTH,  $4.00;  LEATHER,  $5.00. 

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must  have  been  felt  by  every  teacher  of  physiology.  *  *  *  * 
In  conclusion,  we  heartily  congratulate  Prof.  Yeo  on  his  work, 
which  we  can  recommend  to  all  those  who  wish  to  find  within  a 
moderate  compass  a  reliable  and  pleasantly  written  exposition  ot 
all  the  essential  facts  of  physiology  as  the  science  now  stands." — 
The  Dublin  yournal  of  Med.  Science. 

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of  Physiology." — Prof.  H.  P.  Bowditch,  Harvard  Med.  School, 
Boston. 

"  The  brief  examination  I  have  given  it  was  so  favorable  that  I 
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ology."— Prof  L.  B.  How,  Dartmouth  Med.  College,  Hanover, 
N.H. 

RINDFLEISCH. 

THE  ELEMENTS  OF  PATHOLOGY. 

TRANSLATED  BY  WM.  H.  MERCUR,  M.D. 
REVISED   AND   EDITED   BY  PROF.  JAS.  TYSON, 

Of  the  University  of  Pennsylvania. 
263  PAGES.  CLOTH.  PRICE  $2.00. 
*V*It  is  the  object  of  Prof.  Rindfleisch  to  present  in 
this  volume  of  moderate  size  the  fundamental  principles 
of  Pathology  A  large  number  of  the  general  processes 
which  underlie  disease,  a  knowledge  of  which  is  essen- 
tial to  the  practical  physician,  are  plainly  presented. 
They  include,  among  others,  inflammation,  tumor  forma- 
tion,  fever,  derangements  of  nutrition,  including  atrophy, 
derangements  of  the  movement  of  the  blood,  of  blood 
formation  and  blood  purification,  hyperesthesia,  anaesthe- 
sia, convulsions,  paralysis,  etc.  The  well-known  reputa- 
tion of  the  author,  his  thorough  familiarity  with  and  his 
method  of  treating  the  subject,  make  this  most  recent  work 
peculiarly  useful  to  the  student,  as  well  as  to  the  prac- 
ticing physician  who  wishes  to  brush  up  his  pathology. 


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VAN  HARLINGEN  ON  SKIN  DISEASES. 

A  Handbook  of  the  Diseases  of  the  Skin,  their  Di- 
agnosis and  Treatment.  By  Arthur  Van  Harlingen,  M.D., 
Professor  of  Diseases  of  the  Skin  in  the  Philadelphia 
Polyclinic,  Consulting  Physician  to  the  Dispensary  for 
Skin  Diseases,  etc.  Illustrated  by  two  colored  litho- 
graphic plates. 

12mo.  284  PAGES.  CLOTH.  PRICE  $1.75. 
***This  is  a  complete  epitome  of  skin  diseases,  arranged  in  al- 
phabetical order,  giving  the  diagnosis  and  treatment  in  a  concise, 
practical  way.  Many  prescriptions  are  given  that  have  never  been 
published  in  any  text-book,  and  an  article  incorporated  on  Diet. 
The  plates  do  not  represent  one  or  two  cases,  but  are  composed  of  a 
number  of  figures,  accurately  colored,  showing  the  appearance  of 
various  lesions,  and  will  be  found  to  give  great  aid  in  diagnosing. 

BYPORD,  DISEASES  OF  WOMEN. 

NEW  REVISED  EDITION. 

The  Practice  of  Medicine  and  Surgery,  as  applied  to  the 
Diseases  of  Women.  By  W.  H.  Byford,  a.m.,  m.d., 
Professor  of  Gynaecology  in  Rush  Medical  College; 
of  Obstetrics  in  the  Woman's  Medical  College ;  Sur- 
geon to  the  Woman's  Hospital;  President  of  the 
American  Gynaecological  Society,  etc.  Third  Edition. 
Revised  and  Enlarged;  much  of  it  Rewritten;  with 
over  1 60  Illustrations.     Octavo. 

PRICE,  CLOTH,  $5.00;  LEATHER,  $6.00. 
"  The  treatise  is  as  complete  a  one  as  the  present  state  of  our 
science  will  admit  of  being  written.  We  commend  it  to  the  diligent 
study  of  every  practitioner  and  student,  as  a  work  calculated  to  in- 
culcate sound  principles  and  lead  to  enlightened  practice  " — New 
York  Medical  Record. 

"  The  author  is  an  experienced  writer,  an  able  teacher  in  his  de- 
partment, and  has  embodied  in  the  present  work  the  results  of  a 
wide  field  of  practical  observation.  We  have  not  had  time  to  read 
its  pages  critically,  but  freely  commend  it  to  all  our  readers,  as  one 
of  the  most  valuable  practical  works  issued  from  the  American 
press." — Chicago  Medical  Examiner. 

MACKENZIE,  THE  THROAT  AND  NOSE. 

By  Morell  Mackenzie,  m.d.,  Senior  Physician  to  the 

Hospital  for  Diseases  of  the  Chest  and  Throat ;  Lecturer 

on  Diseases  of  the  Throat  at  the  London  Hospital,  etc. 

Vol.  I.    Including  the  Pharynx,  Larynx,  Trachea, 

etc.     112  Illustrations.    Cloth,  $4.00 ;  Leather,  $5.00 

Vol.  II.    Diseases  of  the  CEsophagus,  Nose  and 

Naso-pharynx,  with  Formula  and  93  Illustrations. 

Cloth,  $3.00;  Leather,  $4.00 

The  two  volumes  at  one  time,    Cloth,  $6.00 ;  Leather,  $7.50. 


RK522 

Barrett 


B27 


Dental  surgery  for  medical  prac- 
titioners. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 
HK  522  B27  C.1 

Dental  surgery  for  general  practitioners 


2002398990 


^4  m 

Ml* 

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